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

MyEloctate Co-Pay Program

This is a copay assistance program

Provided by: Biogen


TEL: 855-693-5628


FAX: 855-398-7634
Languages Spoken:

English, Others By Translation Service

 

Patient Assistance Applications

 

Generic Name Medications Covered

 
 

Eligibility Requirements   

Insurance Status Must be commercially insured
Those with Part D Eligible? No
Income No limits
Diagnosis/Medical Criteria Medically Necessary as determined by a Doctor
US Residency Required? Must be treated by US licensed healthcare provider and use a US pharmacy
   

Application

Obtaining Call or download
Receiving Not specified
Returning Fax
Doctor's Action Complete section and sign
Applicant's Action Complete section and sign
Decision Communicated Not specified
Decision Timeframe 2 business days, once application process is complete
   

Medication

Amount/Supply Not applicable
Sent To Not applicable
Delivery Time Not applicable
Refill Process Not applicable
Limit Not applicable
Re-application Enrollment is for 12 months and will be renewed if the patient still has commercial insurance.
   

Additional Information

There is a coverage limit of $12,000 per year.

Free Trial Plus Program: receive a free 30-day supply if this is your first prescription of Eloctate. Other restrictions may apply.

MyEloctate also offers the Factor Access Program, which helps with caps and gaps in your insurance, as well as Insurance Counseling. Contact program for more information.


Updated July 05, 2017