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PROVIDER ENROLLMENT FORM


Specialty Pharmacies or Healthcare Providers: Enroll here to assist your eligible patients with their ALYGLO (immune globulin intravenous, human-stwk), 10% Liquid copays.


Financial reimbursement will be issued to this name

Section 1: Pharmacy Location
This section is mandatory, it requires the address and specific information of your pharmacy

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: Alternate financial reimbursement address
This section is optional. It is only required if your pharmacy location (address listed above) wants to re-direct copay 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: Create your account
This section is mandatory, the e-mail address and the password you create here will enable you to log into this portal.

At least 8 characters long


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