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 a benefits investigation through BV360 Reimbursement Solution.
BV360 Reimbursement Solution
Patient Assistance Program Form
Patient Assistance Eligibility Requirements
- Patient must be 18 years of age or older.
- Patient must have a valid prescription.
- Patient must be a resident of the United States or U.S. Territories.
- Patient must have no insurance coverage, or not enough coverage to pay for the Bioventus medication.
- Patient income must fall below 300% of the Federal Poverty Level, which can be found on https://aspe.hhs.gov/poverty-guidelines
- Patient must provide and prescriber must submit with this request a photocopy of one of the following documents that shows total annual income:
- – Previous year’s federal tax return (form 1040 or 1040EZ)
– Wage and tax statements (W-2 forms)
– Two recent paycheck stubs
– Social security, pension, or retirement statements (SSA-1099 or similar)
2019 Federal Poverty Guidelines
*For households with more than 8 people, add $4,420 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