Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 2.
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My Source CSL Behring Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: CSL Behring


TEL: 800-676-4266


ALT PHONE: 844-727-2752
Languages Spoken:

English

Program Website

 

Program Applications and Forms

My Source CSL Behring Patient Assistance Program Application

 

Medications

  • alpha1-proteinase inhibitor human iv (Zemaira) IV
 

Eligibility Requirements   

Insurance Status Must be uninsured or underinsured
Those with Part D Eligible? Contact program for details.
Income At or below 250% of FPL
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Must reside in the US
   

Application

Obtaining Call
Receiving Faxed, emailed or mailed
Returning Fax
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach proof of income and include Medicaid denial letter
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Contact the program for more details.
Sent To Doctor's office, hospital, or pharmacy
Delivery Time Contact Program for Details
Refill Process Contact program for details.
Limit Contact the program for details
Re-application Contact program for details.
   

Additional Information

This program also provides copay assistance.

Call for most recent medications as the list is subject to change: 1-844-727-2752

Updated August 14, 2020


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 2.
 

Prolastin Direct Program

This program provides brand name medications at no or low cost

Provided by: Grifols

c/o Eversana

TEL: 800-305-7881


FAX: 866-588-6940
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

Prolastin Direct Prescription and Enrollment Form/SMN

 

Medications

  • alpha1-proteinase inhibitor human solution; iv (Prolastin-C) Solution; IV
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Not specified
Income Not disclosed
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Must be citizen
   

Application

Obtaining Call, download or apply online
Receiving Complete online, download from website or faxed.
Returning Fax or submit online
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Call or enroll online
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply As prescribed by Doctor
Sent To Varies
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Not specified
   

Additional Information

Co-payment assistance, reimbursement support, and patient assistance programs are available for eligible patients.

Updated September 16, 2020