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Grifols Assurance for Patients (GAP Program for IVIG)
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Grifols PatientCare Program
PO Box 3745
Alhambra, CA 91803
Phone
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(888)325-8579
Ext opt.3
Fax:
(323)441-7166
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Eligibility
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Must have a temporary lapse in insurance coverage. Must also have been treated with Grifols products for 3 continuous months prior to a lapse in coverage through a non-state or federal health insurance plan. Medicare PartD eligibility not specified. Income requirements for this program have not been disclosed. Must be citizen or legal resident. |
| Who Can Apply
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Call to have application faxed, mailed or downloaded from website. Return application via fax or mail. Doctor notified of decision within 5-7 business days. |
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Required
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Primary Immune Deficiency diagnosis required. Doctor must complete and sign the application and attach a letter of medical necessity. Patient must complete application, sign and attach insurance information. |
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Supply
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Amount/supply varies. Doctor's office must contact the company. Refill limit not specified. New application must be completed every 12 months. |
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Ship To
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Ships to Doctor's office, hospital, or pharmacy within 1-3 business days. |
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Note
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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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| Flebogamma DIF |
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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 Grifols Assurance for Patients (GAP Program for IVIG) |
(Requires Acrobat Reader) 
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Grifols Patient Assistance Program (IVIG)
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Grifols PatientCare Program
PO Box 3745
Alhambra, CA 91803
Phone
:
(888)325-8579
Ext opt.3
Fax:
(323)441-7166
|
|
Eligibility
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Must not have any insurance or be eligible for state or federal funded healthcare. Medicare Part D patients are not eligible for this program. Income must be at or below 250% of FPL. Must be citizen or legal resident. |
| Who Can Apply
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Call to have application faxed, mailed or downloaded from website. Return application via fax or mail. Doctor notified of decision within 5-7 business days. |
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Required
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| > |
Primary Immune Deficiency diagnosis required. Doctor must complete and sign the application and attach a letter of medical necessity Patient must complete and sign application. |
|
Supply
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| > |
Amount/supply varies. Doctor's office must contact the company for refills. Refill limit not specified. New application must be completed every 12 months. |
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Ship To
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| > |
Ships to Doctor's office, hospital, or pharmacy within 1-3 business days. |
|
Note
|
| > |
|
| |
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.
|
| Flebogamma DIF |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form Grifols Patient Assistance Program (IVIG) |
| (Requires Acrobat Reader)
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Grifols Free Trial Offer
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,
Phone
:
(844)693-2286
Fax:
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Eligibility
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Must be commercially insured. Medicare Part D patients are not eligible for this program. Income not required for this program. Must reside in the US, be under the direct care of a licensed US physician and receive US health care services. |
| Who Can Apply
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The Doctor should call for an application or download it from the website. Application must be sent to Doctor's office and returned from Doctor's office via fax. Doctor notified of decision. |
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Required
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FDA-approved diagnosis required. Patient must inform Doctor that he/she is in need. Doctor must complete application, sign and attach required documents. |
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Supply
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Up to 3 doses. No refills. Maximum of 12,000 IU. This is a one time program. |
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Ship To
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Ships to Doctor's office or pharmacy within 2 business days. |
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Note
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Resources for HEALTHCARE PROFESSIONALS ONLY.
Free Trial Program: Contact Program for details. |
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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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| Alphanate injection |
| AlphaNine SD injection |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form Grifols Free Trial Offer |
| (Requires Acrobat Reader)
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