| |
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) 
|
| |
|
|