Registered Users Log-in:

E-mail Address:
 

Password:
 

  
Forgot Password?
Registration
 
Patient Assistance Information

 
3 Programs for Flebogamma DIF
 
 
Grifols Assurance for Patients (GAP Program for IVIG)

Grifols PatientCare Program
PO Box 3745
Alhambra, CA 91803
Phone : (888)325-8579 Ext opt.3
Fax: (323)441-7166
Eligibility
> 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
> 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.
Required
> 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.
Supply
> Amount/supply varies. Doctor's office must contact the company. Refill limit not specified. New application must be completed every 12 months.
Ship To
> 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.
 
Download printable Form Grifols Assurance for Patients (GAP Program for IVIG)
(Requires Acrobat Reader
 
 
Grifols Patient Assistance Program (IVIG)

Grifols PatientCare Program
PO Box 3745
Alhambra, CA 91803
Phone : (888)325-8579 Ext opt.3
Fax: (323)441-7166
Eligibility
> 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
> 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.
Required
> 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
> Amount/supply varies. Doctor's office must contact the company for refills. Refill limit not specified. New application must be completed every 12 months.
Ship To
> 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.
 
Download printable Form Grifols Patient Assistance Program (IVIG)
(Requires Acrobat Reader
 
 
Patient Access Network Foundation (PAN)

PO Box 221858
Charlotte, NC 28222
Phone : (866)316-7263
Fax: (866)316-7263
Eligibility
> This is a copay assistance program for patients that have health insurance. The patient's insurance must cover the qualifying medication that they are seeking assistance for. Patient with Medicare Part D will be considered on a case by case basis. Patients must be at or below 400-500% of the federal poverty level, must have a medically appropriate diagnosis/condition and must reside and receive treatment in the US.
Who Can Apply
> Patients or healthcare providers can complete the application online or by phone.
Required
> Patients must call for information or inform their doctor that they are in need. Doctors action will be discussed with the patient and doctor after the request is received.
Supply
> Not applicable
Ship To
> Patient sent card to be used at pharmacy
Note
> *Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance. Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly. Note: All new enrollment is now done electronically or over the phone. Contact program for details.
 
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.
 
Download printable Form
(Requires Acrobat Reader