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

1-833-MyBV360 (692-8360)
MyBV360.com
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