Program Details
HORIZON PHARMA USA, INC.
Horizon By Your Side - Krystexxa
Krystexxa IV
(pegloticase)
|
CONTACT
INFO |
|
Address: |
, |
Phone: |
1-877-633-9521 |
Provider Phone: |
|
Fax: |
1-877-633-9522 |
Website: |
Program Website |
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ELIGIBILITY
|
|
Eligibility
Info: |
Program offers co-pay assistance, reimbursement support, and patient assistance programs for eligible patients.
Patients with Medicare Part D may be eligible, contact program for details.
Income eligibility based on FPL. |
|
Couple |
|
% FPL |
Income at or below: |
Not
Published |
Medical expenses
can be deducted from reported income: |
Not
Published |
Social security requested on form: |
No |
US citizenship/residency specified:
|
Yes |
|
APPLICATION |
|
Attachments
Required: |
Financial
|
Physician
License #
Required: |
Both DEA and State
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Not Published
|
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MEDICATION |
|
Receives: |
Medication
|
Shipped To: |
Provider
|
Quantity in
Shipment: |
Varies |
Delivery Time: |
Not Published
|
Re-application
Policy: |
Not Published |
Refill Policy: |
Not Published
|
Other Information: |
|
|
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Last Updated: 04/04/2024
www.RxAssist.org
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