Contact info
- Phone
- 1-833-692-8360
- Fax
- 1-833-692-8329
Eligibility
- Patient must have no insurance coverage, or not enough coverage to pay for the medication.
- Income limit, single
- 300% of the federal poverty level
- Income limit, couple
- 300% of the federal poverty level
- Medical expenses can be deducted
- Not published
- Social Security number asked for
- No
- US citizenship or residency required
- Yes
Not sure where your income falls? See this year's federal poverty guidelines (opens in a new tab).
Application process
- Documents to attach
- Proof of income
- Prescriber license number
- NPI number
- Who can sign
- Physician
- Application can be faxed
- Yes
- Decision letter sent to
- Not published
Getting the medication
- Patient receives
- Varies
- Shipped to
- Provider
- Supply per shipment
- Not published
- Time to first delivery
- Not published
- Refills
- Not published
- Staying enrolled
- Not published
Medications covered
- Durolane (hyaluronic acid injection)
- Gelsyn-3 (3 injection hyaluronic acid)
- Supartz (sodium hyaluronate)