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Octapharma Reimbursement
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121 River Street, Suite 1201
Hoboken, NJ 07030
Phone
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(800)554-4440
Fax:
(800)554-6744
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Eligibility
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This program is for Healthcare Professionals Only. Insurance eligibility, income requirements and citizenship requirements for this program have not been disclosed. Patients must have a medically appropriate diagnosis. |
| Who Can Apply
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Doctors or the doctor's office must call to have an application sent to their office. |
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Required
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Doctors must complete and sign the application. |
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Supply
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Up to 1 month supply |
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Ship To
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Not specified |
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Note
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This program is intended for US HEALTHCARE PROFESSIONALS and/or Professionals involved in Healthcare Reimbursement ONLY. |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
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| Wilate liquid |
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Octapharma Wilate Bridge Program
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1620 Century Center Parkway, Suite 109
Memphis, TN 38134
Phone
:
(877)794-5283
Fax:
(877)920-1115
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Eligibility
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Medicare Part D patients are not eligible for this program. Income requirements for this program have not been disclosed. Patients must have an FDA-approved diagnosis and must reside in the US. |
| Who Can Apply
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The doctor or doctor's office must call to have an application mailed or download the application. |
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Required
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Doctors must complete a section, sign and attach a prescription. Patients must also complete a section and sign. The application must then be faxed from the doctor's office. |
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Supply
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The Octapharma Wilate BridgeTrial Voucher is for a maximum of one trial shipment per patient’s lifetime: This trial voucher may be redeemed for a trial supply of Wilate 500 IU vials or 1000 IU vials, up to the lesser of 5000IUs or 30 days supply, as prescribed. |
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Ship To
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Patient sent card to be used at pharmacy |
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Note
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This program is intended for US HEALTHCARE PROFESSIONALS and/or Professionals involved in Healthcare Reimbursement ONLY. The Doctor must contact the program. |
| |
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
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| Wilate liquid |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form |
| Download printable Form |
(Requires Acrobat Reader) 
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