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MyAlprolix Program

This is a copay assistance program

Provided by: Bioverativ

TEL: 855-692-5776

FAX: 855-398-7634
Languages Spoken:

English, Others By Translation Service

Program Website


Patient Assistance Applications

Bioverativ Program Enrollment Form (Alprolix)


Brand Name Medications Covered

  • Alprolix powder; lyophilized

Generic Name

  • coagulation factor IX (recombinant), fc fusion protein powder; lyophilized

Eligibility Requirements   

Insurance Status *Contact program for details.
Those with Part D Eligible? No
Income Household income at or less than $150,000
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


Obtaining Call or download
Receiving Faxed or downloaded from website
Returning Fax
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient and Doctor are notified
Decision Timeframe Varies


Amount/Supply 30 day supply
Sent To Doctor's office or patient's home
Delivery Time Once approved; shipped next business day
Refill Process Patient or Doctor must contact company
Limit Contact the program for details
Re-application New application every 12 months

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 Alprolix. Other restrictions may apply.

Bioverativ 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 October 05, 2018