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Patient Assistance Information

 
 
 
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