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Patient Assistance Information

 
 
 
Krystexxa Connect Reimbursement Hotline

PO Box 5667
Louisville, KY 40255
Phone : 877-633-9521
Fax: 877-633-9522
Eligibility
> 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
> 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.
Required
> 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.
Supply
> 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.
Ship To
> 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