Financial Assistance

Alcresta Therapeutics provides financial assistance programs for RELiZORB to eligible patients. Click the tab to expand and learn more about each program.

RELiZORB Out-of-Pocket Assistance Program

 

Assistance with out-of-pocket expenses, such as co-pays, co-insurance or deductibles. More >

For eligible patients with commercial health insurance, the RELiZORB Out-of-Pocket Assistance Program assists with out-of-pocket expenses, which can include co-pays, co-insurance or deductibles.

Who is Eligible?

The RELiZORB Out-of-Pocket Assistance Program is open to individuals who:

  • Have commercial insurance
  • Are prescribed RELiZORB

How Much Could a Patient Save?

The program requires the patient to pay a minimum of $25 or the full amount of their co-pay/deductible or co-insurance, whichever is less, for each 30 count box of RELiZORB.

No out-of-pocket assistance card is required — the benefit will be automatically deducted from the patient’s bill.

How to Enroll in the RELiZORB Out-of-Pocket Assistance Program

If the patient has commercial insurance, he or she will be automatically enrolled in the program when RELiZORB Support Services reviews the patient’s commercial insurance benefits. Enrollment in the program is subject to confirmation of eligibility.

RELiZORB Patient Assistance Program

 

Financial assistance for patients with limited options. More >

RELiZORB is available at no cost to patients experiencing financial difficulties through the RELiZORB Patient Assistance Program (PAP). Eligible patients typically have no healthcare coverage for the requested product and do not have access to alternative sources of coverage or funding. All applications are reviewed on a case-by-case basis to support the RELiZORB Patient Assistance Program’s purpose of providing products at no cost to individuals in need.

How to Enroll in the RELiZORB Patient Assistance Program

An enrollment form is available from RELiZORB Support Services by calling 1-844-RELiZORB (1-844-735-4967). The following checklist should be used when completing the application.

Checklist for Submitting an Application:

□ Ensure all sections of the application are completed

□ Attach current proof of income (tax return, W2, pay stub) for all in household

□ Prescriber’s signature/date is required on Page 1 of the application

□ Patient’s signature/date is required on Page 2 and Page 3 of the application

□ Complete the Patient Authorization Form

 

Fax or Mail the Completed Documentation to:

RELiZORB Patient Assistance Program
c/o RELiZORB Support Services
2560 Lord Baltimore Drive, Suite 222
Baltimore, Maryland 21244

Fax: 1-844-890-1900

 

Enrollment in the program is subject to confirmation of eligibility.

 

RELiZORB Support Services:
Here to Help

With one call, patients using RELiZORB have access to a range of helpful support services. A dedicated program coordinator is standing by.

1-844-RELiZORB (1-844-735-4967)