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PROVIDER ENROLLMENT FORM


Specialty Pharmacies or Healthcare Providers: Enroll here to assist your eligible patients with their ALPHANATE® (antihemophilic factor/von Willebrand factor complex [human]) and AlphaNine® SD (coagulation factor IX [human]) co-pays.


Financial reimbursement will be issued to this name

Section 1 This section is mandatory. It requires the specifics of your pharmacy location.

Setting of this pharmacy location

Location street address

Location address line 2

Location city

Location state

Location ZIP code (5-digits e.g. 91101)

Location phone (including area code)

Location fax number

First and last name of the billing contact at this location

Please provide the 10-digit NPI number for this location

Section 2 This section is optional. It is only required if your pharmacy location (address listed above) wants to re-direct co-pay assistance reimbursement to a different address. If left blank, reimbursement will be sent to the address listed in Section 1 above.

Street address where financial reimbursement would be sent

Financial reimbursement address line 2

Financial reimbursement city

Financial reimbursement state

Financial reimbursement ZIP code (5-digits e.g. 91101)

First and last name of the financial reimbursement contact

Financial reimbursement contact direct phone (including area code)

Section 3 This section is mandatory. The e-mail address and password provided here will enable you to log in to this portal.

At least 8 characters long


Important Safety Information: ALPHANATE® (antihemophilic factor/von Willebrand factor complex [human])

ALPHANATE is contraindicated in patients who have manifested life-threatening immediate hypersensitivity reactions, including anaphylaxis, to the product or its components.

Anaphylaxis and severe hypersensitivity reactions are possible with ALPHANATE. Discontinue use of ALPHANATE if hypersensitivity symptoms occur, and initiate appropriate treatment.

Development of procoagulant activity-neutralizing antibodies (inhibitors) has been detected in patients receiving FVIII-containing products. Carefully monitor patients treated with AHF products for the development of FVIII inhibitors by appropriate clinical observations and laboratory tests.

Thromboembolic events have been reported with AHF/VWF complex (human) in VWD patients, especially in the setting of known risk factors.

Intravascular hemolysis may occur with infusion of large doses of AHF/VWF complex (human).

Rapid administration of a FVIII concentrate may result in vasomotor reactions.

Because ALPHANATE is made from human plasma, it may carry a risk of transmitting infectious agents, eg, viruses, the variant Creutzfeldt-Jakob disease (vCJD) agent, and, theoretically, the Creutzfeldt-Jakob disease (CJD) agent, despite steps designed to reduce this risk.

Monitor for development of FVIII and VWF inhibitors. Perform appropriate assays to determine if FVIII and/or VWF inhibitor(s) are present if bleeding is not controlled with expected dose of ALPHANATE.

The most frequent adverse drug reactions reported with ALPHANATE in >1% of infusions were pruritus, headache, back pain, paresthesia, respiratory distress, facial edema, pain, rash, and chills.

Please see ALPHANATE full Prescribing Information for complete prescribing details.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.


Important Safety Information: AlphaNine® SD (coagulation factor IX [human])

AlphaNine SD is made from human plasma. Plasma products carry a risk of transmitting infectious agents, including viruses, and theoretically, the Creutzfeldt-Jakob disease (CJD) agent, despite steps designed to reduce this risk.

Incidences of thrombosis or disseminated intravascular coagulation (DIC) have been reported following administration of Factor IX Complex concentrates which contain high amounts of Factor II, VII and X. AlphaNine SD contains low, nontherapeutic levels of Factor II, VII and X.

Following administration in surgery patients and individuals with known liver disease, the physician should closely observe the patient for signs and symptoms of potential disseminated intravascular coagulation.

Allergic type hypersensitivity reactions, including anaphylaxis, have been reported for all factor IX products. The administration of plasma preparations may cause allergic reactions, mild chills, nausea or stinging at the infusion site.

Nephrotic syndrome has been reported following attempted immune tolerance induction with factor IX products in hemophilia B patients with factor IX inhibitors and a history of severe allergic reactions to Factor IX.

In order to minimize the possibility of thrombogenic complications, dosing guidelines should be strictly followed.

AlphaNine SD should not be administered at a rate exceeding 10 mL/ minute. Rapid administration may result in vasomotor reactions.

Please see AlphaNine full Prescribing Information for complete prescribing details.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.