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Grifols Free Trial Offer
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Phone
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(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 |
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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 Free Trial Offer |
(Requires Acrobat Reader) 
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Grifols Patient Assistance Program
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Grifols-Factors for Health
PO Box 220663
Charlotte, NC 28222
Phone
:
(844)693-2286
Fax:
(888)324-1821
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Eligibility
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Must be uninsured or have a temporary lapse in insurance coverage. Medicare Part D patients are not eligible for this program. Income must be at or below 400% of FPL. 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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Call to have application faxed or mailed. Return application via fax or mail. Doctor notified of decision within 5-7 business days. |
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Required
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FDA-approved diagnosis required. Doctor must complete application, sign and return required documents. Patient must call to enroll. |
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Supply
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Up to 30 day supply. Doctor's office must contact the company fro refills. Maximum of 100,000 IU for a 12 month supply. 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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This program also provides copay assistance. |
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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.
|
| Alphanate injection |
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