Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 5.
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Grifols Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: Grifols Biologicals, Inc.

Grifols-Factors for Health
PO Box 220663
Charlotte, NC 28222-0663

TEL: 844-693-2286


FAX: 888-324-1821
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Grifols Patient Assistance Program: Contact program

 

Medications

  • antihemophilic factor human (Alphanate) 
 

Eligibility Requirements   

Insurance Status Must be uninsured or have a temporary lapse in insurance coverage.
Those with Part D Eligible? No
Income At or below 400% of FPL
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Must reside in the US, be under the direct care of a licensed US physician and receive US health care services
   

Application

Obtaining Call
Receiving Faxed or mailed
Returning Fax or mail
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Call to enroll
Decision Communicated Doctor notified
Decision Timeframe 5-7 business days
   

Medication

Amount/Supply Up to 30 day supply
Sent To Doctor's office, hospital, or pharmacy
Delivery Time 1-3 business days
Refill Process Doctor's office must contact the company
Limit Maximum of 100,000 IU for a 12 month supply
Re-application New application every 12 months
   

Additional Information

This program also provides copay assistance.


Updated June 20, 2018


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 5.
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Hematology Support Center

This program provides brand name medications at no or low cost

Provided by: Shire Pharmaceuticals


TEL: 888-229-8379


Languages Spoken:

English

Program Website

 

Program Applications and Forms

Hematology Support Center Enrollment Form: Contact program

 

Medications

  • antihemophilic factor human (Hemofil-M) 
 

Eligibility Requirements   

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

Application

Obtaining Call or download from Programs website
Receiving Varies
Returning Fax
Doctor's Action Varies
Applicant's Action Call for information or inform doctor that he/she is in need
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Not specified
Sent To Varies
Delivery Time Not specified
Refill Process Varies per medication
Limit Not specified
Re-application Not specified
   

Additional Information

Eligibility determined on a case-by-case basis.

Free Trial Program, Patient Assistance Programs and Co-payment Assistance are available for eligible patients. Contact program for details.


Updated August 02, 2018


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 5.
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Patient Access Network Foundation (PAN)

This is a copay assistance program

Provided by: Patient Access Network Foundation


TEL: 866-316-7263


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Patient Access Network Foundation (PAN) Application: Contact program

 

Medications

  • antihemophilic factor (human) injection
  • antihemophilic factor human
  • antihemophilic factor (human) vial; single-use
 

Eligibility Requirements   

Insurance Status *See Additional Information section below
Those with Part D Eligible? Determined case by case
Income Between 400-500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Complete online or by phone
Returning Complete online or by phone
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Call for information or inform doctor that he/she is in need
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved; shipped same day
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months
   

Additional Information

*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.

Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.

Note: All new enrollment is now done electronically or over the phone. Contact program for details.


Updated July 10, 2018


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 4 of 5.
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CSL Behring Care Coordination Center

Provided by: CSL Behring

PO Box 368
Lewisville, TX 75067

TEL: 800-676-4266


Languages Spoken:

English

Program Website

 

Program Applications and Forms

CSL Behring Care Coordination Center: Contact program

 

Medications

  • antihemophilic factor (human) vial; single-use (Monoclate-P) Vial; Single-Use
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? No
Income Not disclosed
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must be citizen or legal resident
   

Application

Obtaining Call. *See Additional Information section below
Receiving Faxed or mailed
Returning Fax
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Call for information or inform doctor that he/she is in need
Decision Communicated Decision made during phone screening
Decision Timeframe Not specified
   

Medication

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

Additional Information

Since drug availability changes based on inventory, call to make sure requested drug is available.

This program lists medications that may be covered under a different CSL Behring savings program: Contact Program for more details
*877-355-4447: Carimune, Hizentra & Privigen
*866-936-2472: Zemaira

The Berinert Copay BEnefit covers up to $12,000 in eligible out-of-pocket expenses per year.
Patient must be diagnosed with HAE (Hereditary Angleodema)

Assurance Program: Once enrolled in the Program, Patient will begin earning an Award Certificate for every 3 consecutive months of therapy use. Each Certificate is worth a 1-month supply of therapy (up to the maximum amount redeemable) and can be redeemed in the event of a lapse in insurance.


Updated August 01, 2018


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 5 of 5.
 

Grifols Free Trial Offer

Provided by: Grifols Biologicals, Inc.


TEL: 844-693-2286


Languages Spoken:

English

Program Website

 

Program Applications and Forms

Grifols Free Trial Offer: Contact program

 

Medications

  • antihemophilic factor human (Alphanate) 
 

Eligibility Requirements   

Insurance Status Must be commercially insured
Those with Part D Eligible? No
Income Not Required
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Must reside in the US, be under the direct care of a licensed US physician and receive US health care services
   

Application

Obtaining The Doctor should call for an application or download it from the website
Receiving Sent to Doctor's office
Returning Fax from Doctor's office
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Inform Doctor that he/she is in need
Decision Communicated Doctor notified
Decision Timeframe Not specified
   

Medication

Amount/Supply Up to 3 doses
Sent To Doctor's office or pharmacy
Delivery Time Within 2 business days
Refill Process No Refills
Limit Maximum of 12,000 IU
Re-application This is a one time program
   

Additional Information

Resources for HEALTHCARE PROFESSIONALS ONLY.

Free Trial Program: Contact Program for details


Updated June 20, 2018