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Program Details

Grifols Patient Assistance Program

Alphanate injection (antihemophilic factor/von willebrand factor complex (human))
Address: Grifols -Factors for Health
PO Box 220663
Charlotte, NC 28222-0663
Phone: 1-844-693-2286 Provider Phone:
Fax: 1-888-324-1821 Website: Program Website
Eligibility Info:
  • Patient must not have insurance or have a temporary lapse in insurance.
  • Patient must not be eligible for state or federally funded healthcare programs and meet program income guidelines below.
  • Income at or below: Single 400 % FPL
      Couple 400 % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: No
    US citizenship/residency specified: Yes
    Attachments Required: None
    Physician License #
    Not Required
    Prescriber Signature
    Application may be
    Eligibility determination
    letter sent:
    Not Published
    Receives: Medication
    Shipped To: Provider
    Quantity in Shipment: Up to 30-day supply
    Delivery Time: 0-1 week
    Re-application Policy: New application every 12 months
    Refill Policy: Physician's office must contact the program.
    Other Information:
  • Co-pay assistance is also available.
  • Last Updated: 01/20/2017




    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.


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