Enroll in Rare Blood Disorder Support

Support starts with enrollment

It takes just a few steps. There are two ways you can enroll.

Enroll online

Fill out the form for your patient online. If your patient is unable to provide consent in your office, HemAssist can reach out to get the patient’s consent directly.

Enroll now

Fax your enrollment form

Select your treatment, download, and bring this enrollment form to your HCP office. They can complete it and fax it to HemAssist at 1-855-398-7634.

ALPROLIX^® [Coagulation Factor IX (Recombinant), Fc Fusion Protein] Enrollment Form

ALTUVIIIO^® [antihemophilic factor (recombinant), Fc‑VWF‑XTEN fusion protein‑ehtl] Enrollment Form

CABLIVI^® (caplacizumab-yhdp) Enrollment Form

ELOCTATE^® [Antihemophilic Factor (Recombinant), Fc Fusion Protein] Enrollment Form

Qfitlia™ (fitusiran) Enrollment Form

Please see full Prescribing Information, including Boxed WARNING.

WAYRILZ™ (rilzabrutinib) Enrollment Form

Copay Assistance* enrollment

HemAssist may be able to help eligible commercially-insured patients gain access to treatment for as little as $0.

Copay Assistance Enrollment for ALPROLIX, ALTUVIIO, ELOCTATE and QFITLIA

Please see full Prescribing Information, including Boxed WARNING for QFITLIA

Copay Assistance enrollment for CABLIVI

Copay Assistance enrollment for WAYRILZ

References

^{* Not valid if the patient is utilizing a state or federally funded health insurance program such as Medicare (including Medicare Part D), Medicaid, Medigap, VA, DoD, TRICARE®, state pharmaceutical assistance program, etc. to pay in part or in full for their prescription. Not valid where prohibited by law. Sanofi reserves the right to modify or terminate the Copay Program at any time without notice. Savings by patients may vary depending on their out-of-pocket costs. The program is intended to help patients afford their prescription. Patients may have insurance plans that attempt to dilute the impact of the assistance available under the program. In those situations, the program may change its terms.}