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Krystexxa Connect Reimbursement Hotline
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PO Box 5667
Louisville, KY 40255
Phone
:
877-633-9521
Fax:
877-633-9522
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Eligibility
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This program is intended for patients that don't have prescription coverage, except Medicare Part D patients are eligible for this program. Patient's income must be at or below 400% of FPL & Patient must be a US citizen or legal resident. |
| Who Can Apply
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Call for application to be faxed or mailed, or download from the website. Application must be faxed back to company from the Doctor's office. |
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Required
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Doctor complete section, sign, include copy of DEA or state license number. Patient complete section, sign, attach proof of income and valid photo ID. Doctor will be notified in 24-48hrs. |
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Supply
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Up to a 2 week supply. Doctor/Doctor's office must complete replacement form for refills, with no refill limit. A new application must be submitted every 6 months. |
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Ship To
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Medication will be sent to an authorized healthcare facility within 2 business days. |
|
Note
|
| > |
|
| |
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
|
| Krystexxa injection |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form Krystexxa Connect Reimbursement Hotline |
(Requires Acrobat Reader) 
|
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|
|
| |
Krystexxa Connect Patient Assistance Program
|
PO Box 5667
Louisville, KY 40255
Phone
:
877-633-9521
Fax:
877-633-9522
|
|
Eligibility
|
| > |
This program is intended for patients that have no prescription insurance, except Medicare part D patients are eligible for this program. Income must be at or below 400% of FPL & patient must be a citizen or legal resident. |
| Who Can Apply
|
| > |
Doctor/Doctor's office must call for faxed or mailed application or download application from website. Application must be faxed back to company from Doctor's office. Doctor will be notified within 24-48hrs. |
|
Required
|
| > |
Doctor must complete section, sign, include copy of DEA or state license number. Patient must complete section, sign, attach proof of income and valid photo ID. |
|
Supply
|
| > |
Up to a 2 week supply. Doctor/Doctor's office must complete replacement form for refills with no refill limit. New application must be completed every 6 months. |
|
Ship To
|
| > |
Medication will be shipped to an authorized healthcare facility within 2 business days. |
|
Note
|
| > |
|
| |
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
|
| Krystexxa injection |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form Krystexxa Connect Patient Assistance Program |
| (Requires Acrobat Reader)
|
| |
|
|