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PROVIDER ENROLLMENT FORM


Specialty Pharmacies or Healthcare Providers: Enroll here to assist your eligible patients with their COAGADEX (Coagulation Factor X, 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


Indications for COAGADEX

COAGADEX, a plasma-derived blood coagulation factor X concentrate, is indicated in adults and children (aged 12 years and above) with hereditary factor X deficiency for:

Limitation of use

Perioperative management of bleeding in major surgery in patients with severe hereditary factor X deficiency has not been studied.


Important Safety Information

COAGADEX is contraindicated in patients with known hypersensitivity to any of the components of the product.

Allergic type hypersensitivity reactions, including anaphylaxis, are possible with COAGADEX. If symptoms occur, patients should discontinue use of the product immediately and contact their physician.

The formation of neutralizing antibodies (inhibitors) to factor X is a possible complication in the management of individuals with factor X deficiency. Carefully monitor patients taking COAGADEX for the development of inhibitors by appropriate clinical observations and laboratory tests.

COAGADEX is made from human plasma and may contain infectious agents, e.g. viruses, the variant Creutzfeldt-Jakob disease (vCJD) agent and, theoretically, the Creutzfeldt-Jakob disease (CJD) agent. No cases of transmission of viral diseases, vCJD or CJD, have been associated with the use of COAGADEX.

In clinical studies, the most common adverse reactions (frequency ≥5% of subjects) with COAGADEX were infusion site erythema, infusion site pain, fatigue and back pain.

Please see full prescribing information for Coagadex.

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.


Coagadex® is a registered trademark of Bio Products Laboratory U.S.A., Inc.
Coagadex is manufactured by Bio Products Laboratory U.S.A., Inc. and distributed by Bio Products Laboratory U.S.A., Inc.

US/X/0319/0016