Alkermes HIFT

The Alkermes Inpatient Free Trial Program is available only to inpatient hospital and crisis stabilization unit pharmacies that are unable to accept PDMA samples and are validly licensed under applicable state law. To receive free trial units for appropriate patients, registration and agreement to program Terms and Conditions is required.

To participate in the Alkermes Free Trial Program, please begin the registration process by completing the required information below. When providing state license information, please be sure to enter as shown on license (ie name as shown and/or state license number). We will process your request as soon as possible.

Asterisks (*) Indicate Mandatory Fields

Pharmacist Information

First Name:

Last Name:

Professional Designation:

Select aDesignation

Pharmacist State Licensure:

Pharmacist State License Number:

Confirm Pharmacist State License Number

Pharmacist Email:

Confirm Pharmacist Email:

Password:

Confirm Password:

Hospital or Crisis Stabilization Unit Pharmacy Ship to Information

Hospital or Crisis Stabilization Unit Name:

Hospital or Crisis Stabilization Unit NPI Number:

Confirm Hospital or Crisis Stabilization Unit NPI Number:

Address 1:

Address 2:

City

State:

Zip Code:

Phone Number

Fax

Pharmacy State Licensure

Pharmacy State License Number

Confirm Pharmacy State License Number

GLN Number: (Numeric Values Only)

SGLN Number:

DSCSA Exempt

Receive EPCIS files via AS2 or SFTP connection:

Receive EPCIS files via sftp for serialization data.

Receive credentials to login to a portal to confirm serialization data.

Product Selection

Select Product:

Select Product

In order to participate in the Hospital Inpatient Free Trial Program and receive free trial units on behalf of your inpatients, the following terms and conditions must be accepted. You are required to check all mandatory boxes (noted with an asterisk) indicating you agree, understand and will follow the terms and conditions of the program. Failure to follow the terms and conditions may result in the termination of your ability to receive free trial units for your patients under this program.

Terms & Conditions

Please review the Terms and Conditions required for the Alkermes Hospital Inpatient Free Trial Program (Program). You must indicate your acceptance of the following Program Terms and Conditions in order to participate in this Program.

Terms and Conditions

By providing the above information and clicking on the below SUBMIT button, the undersigned certifies that:

I have read, understood and agree to comply with the Program terms and conditions.
I certify that I am a licensed pharmacist eligible to receive and dispense Alkermes product(s).
I certify that I am an authorized representative of, and can bind, the Participating Hospital to the Program terms and conditions.
I certify that the Program Product may be dispensed only with a valid prescription from a provider licensed or authorized under state law to prescribe and only for use in Participating Hospital.
I acknowledge that Program Product is for the benefit of patients and certify that Program Product will not be sold, traded, bartered, or returned for credit and that I will not separately bill the patient, the patient's insurance or any government healthcare program for such product. My Participating Hospital will properly report receipt of Program Product at no charge on any cost report or as otherwise required.
I acknowledge that there is no obligation to continue the use of Alkermes product(s) or to purchase any Alkermes product(s) for any patient receiving Program Product, and I will inform participants in this Program of this fact.
I confirm that all information provided in the registration is accurate and true.

March 2024

Certify and Register by Clicking Submit Below