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Patient Assistance Information

1 Program for Hyalgan vial
hHyalgan Reimbursement Services and Patient Assistance Program

PO Box 5817
Louisville, KY 40255
Phone : (866)749-2542
Fax: (877)366-0584
> This program is intended for patients with no prescription coverage. Medicare partD patients are eligible if the medication is not covered. Income must be at or below 250% of FPL. Must be a UD citizen or legal resident.
Who Can Apply
> Call to have application faxed or download from website. Application must be faxed back to the company. Doctor will be notified within 48hrs of decision.
> Must have FDA-approved diagnosis. Doctor must complete and sign application. Patient must complete application, sign and attach insurance information.
> Amount/supply varies. New prescriptions required for each refill. Refill limit not specified. New application must be completed yearly.
Ship To
> Medication ships to Doctor's office within 2-3 days.
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.
Hyalgan vial