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Patient Assistance Information

 
 
 
Grifols Free Trial Offer


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Phone : (844)693-2286
Fax:
Eligibility
> 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
> 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.
Required
> FDA-approved diagnosis required. Patient must inform Doctor that he/she is in need. Doctor must complete application, sign and attach required documents.
Supply
> Up to 3 doses. No refills. Maximum of 12,000 IU. This is a one time program.
Ship To
> Ships to Doctor's office or pharmacy within 2 business days.
Note
> Resources for HEALTHCARE PROFESSIONALS ONLY. Free Trial Program: 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.
 
Alphanate injection
AlphaNine SD injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Grifols Free Trial Offer
(Requires Acrobat Reader