Eloctate Free Trial Plus Program

Funded

About

The Eloctate Free Trial Plus Program offers an excellent opportunity for patients to access Eloctate for the first time with a free 30-day supply. This program is specifically designed to facilitate easy access to Eloctate for new patients under the care of a licensed physician in the United States or Puerto Rico. By completing an enrollment form through their healthcare provider, patients can enjoy the benefits of Eloctate through this convenient program.

Insurance requirements: Commercially insured, Underinsured, Uninsured

Enrollment Forms

Enrollment Form

Benefits

•1 maximum fills per year

Program Requirements

•Enrollment Required: Yes

•Coverage Required: No

•Needs Based: No

•Activation Required: No

Program Details

•Patient can receive their first 30day supply of ELOCTATE with a valid prescription from their healthcare provider

•Patient and HCP must complete the enrollment Form and the physician should fax the form to 18553987634

•For questions, call 18556935628 MondayFriday 8 AM8 PM ET

Enrollment Forms

Enrollment Form