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Krystexxa Connect Patient Assistance Program
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PO Box 5667
Louisville, KY 40255
Phone
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877-633-9521
Fax:
877-633-9522
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Eligibility
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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
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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. |
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Required
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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. |
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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. New application must be completed every 6 months. |
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Ship To
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Medication will be shipped to an authorized healthcare facility within 2 business days. |
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Note
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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.
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| Krystexxa injection |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form Krystexxa Connect Patient Assistance Program |
(Requires Acrobat Reader) 
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