Registered Users Log-in:

E-mail Address:
 

Password:
 

  
Forgot Password?
Registration
 
Patient Assistance Information

 
2 Programs for Wilate liquid
 
 
Octapharma Reimbursement

121 River Street, Suite 1201
Hoboken, NJ 07030
Phone : (800)554-4440
Fax: (800)554-6744
Eligibility
> 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
> Doctors or the doctor's office must call to have an application sent to their office.
Required
> Doctors must complete and sign the application.
Supply
> Up to 1 month supply
Ship To
> Not specified
Note
> This program is intended for US HEALTHCARE PROFESSIONALS and/or Professionals involved in Healthcare Reimbursement ONLY.
 
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.
 
Wilate liquid
 
 
 
Octapharma Wilate Bridge Program

1620 Century Center Parkway, Suite 109
Memphis, TN 38134
Phone : (877)794-5283
Fax: (877)920-1115
Eligibility
> 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
> The doctor or doctor's office must call to have an application mailed or download the application.
Required
> 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.
Supply
> 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.
Ship To
> Patient sent card to be used at pharmacy
Note
> 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.
 
Wilate liquid
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
Download printable Form
(Requires Acrobat Reader