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If your patient is covered under

Medical Benefits
Pharmacies must register here to request assistance for their eligible ALYGLO patients covered under medical benefits.
Pharmacy Benefits
If the patient’s primary payer drug claim is billed under pharmacy benefits, submit the claim to the primary payer first. If the patient requires co-pay assistance, submit the balance due to Medmonk as a secondary payer (COB - Coordination of Benefits) using the BIN: 016664, PCN: MEDMONK, and Cardholder ID: MEDMONK
Timely Filing
Claims must be received within 30 days of dispense date. For medical benefits, EOBs must be submitted within 120 days of claim submission.

Payer Sheet
Please use this Payer Sheet if your organization does not already have Medmonk enlisted as a payer.



This program is subject to change or discontinuation by GC Biopharma at any time, for any reason, and with or without prior notice. This portal is administered by Medmonk for the ALYGLO Co-Pay Assistance Program.

INDICATION

ALYGLO™ is indicated for the treatment of primary humoral immunodeficiency (PI) in adults aged 17 years and older. This includes, but is not limited to, congenital agammaglobulinemia, common variable immunodeficiency (CVID), Wiskott-Aldrich syndrome, and severe combined immunodeficiencies.

IMPORTANT SAFETY INFORMATION

WARNING: THROMBOSIS, RENAL DYSFUNCTION and ACUTE RENAL FAILURE

  • Thrombosis may occur with immune globulin intravenous (IGIV) products, including ALYGLO. Risk factors may include: advanced age, prolonged immobilization, hypercoagulable conditions, history of venous or arterial thrombosis, use of estrogens, indwelling vascular catheters, hyperviscosity, and cardiovascular risk factors.
  • Renal dysfunction, acute renal failure, osmotic nephropathy, and death may occur with the administration of IGIV products in predisposed patients.
  • Renal dysfunction and acute renal failure occur more commonly in patients receiving IGIV products containing sucrose. ALYGLO does not contain sucrose.
  • For patients at risk of thrombosis, renal dysfunction or renal failure, administer ALYGLO at the minimum dose and infusion rate practicable. Ensure adequate hydration in patients before administration. Monitor for signs and symptoms of thrombosis and assess blood viscosity in patients at risk for hyperviscosity.

  • For more information about ALYGLO, please see full Prescribing Information

    You are encouraged to report negative side effects of prescription drugs to GC BioPharma USA. Email medicalinfo@gcbiopharmausa.com or call 1-833-426-6426