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Patient Assistance Information

Krystexxa Connect Patient Assistance Program

PO Box 5667
Louisville, KY 40255
Phone : 877-633-9521
Fax: 877-633-9522
> 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.
> 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.
> 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.
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