Patient Assistance Program
Bioventus is committed to providing access to SUPARTZ FX, GELSYN-3 and DUROLANE to patients without the financial resources to pay for the treatment by providing Patient Assistance Product at no cost. To request assistance for treatment of a patient, please complete and return one of the following Patient Assistance Forms to Bioventus Active Healing Therapies Customer Service via fax (866.832.7284) or email (CustomerServiceUSA@bioventusglobal.com).
Patient Assistance Forms
• SUPARTZ FX Patient Assistance Form
• GELSYN-3 Patient Assistance Form
• DUROLANE Patient Assistance Form
Patient Assistance Eligibility Requirements
- A Patient Assistance Form must be submitted for each patient.
- Patient must have an annual income of ≤250% of the current Federal Poverty Level.
2018 Federal Poverty Guidelines
| Family Size | 250% |
| 1 | $30,350 |
| 2 | $41,150 |
| 3 | $51,950 |
| 4 | $62,750 |
| 5 | $73,550 |
| 6 | $84,350 |
| 7 | $95,150 |
| 8 | $105,950 |
*For households with more than 8 people, add $4,320 for each additional person per year. Chart is for 48 contiguous states and the District of Columbia; for Hawaii and Alaska please visit http://aspe.hhs.gov