RELiZORB Financial Assistance Programs Available to Help You

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Bridge to Reimbursement Program

Provides you with access to RELiZORB if the coverage process is anticipated to take longer than expected. Through this program, you may receive bridge product while the insurance coverage process is underway. Once coverage is obtained, you'll be transitioned to a specialty pharmacy provider who will fill your subsequent orders.

Out-of-Pocket Assistance Program

The program is open to individuals who:

  • Have commercial insurance
  • Are prescribed RELiZORB

If You Qualify, Enrollment in the Program is Automatic

If you are eligible, you will be enrolled in the program when RELiZORB Support Services reviews your commercial insurance benefits. Enrollment in the program is subject to confirmation of eligibility.

How Much Could I Save?

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

There is no out-of-pocket assistance card required — your benefit will be automatically deducted from your bill.*

*The program provides a maximum $300 benefit for each 30-count pack.

Program Terms and Conditions

  • This program covers the cost of RELiZORB out-of-pocket costs. Examples of the types of out-of-pocket expenses that are covered include co-payment, co-insurance, and/or deductibles
  • Eligible patients must have a prescription for RELiZORB
  • Eligible patients must have commercial insurance that covers RELiZORB
  • Persons enrolled in any government healthcare program, such as Medicare, Managed Medicare, Medicaid, Managed Medicaid, Tricare, Triwest, and Veterans Administration are not eligible for the RELiZORB Out-of-Pocket Assistance Program
  • All coverage requirements mandated by the insurance company of the eligible patient must be satisfied in order for the program to take effect
  • Patients who move from commercial to federally funded insurance will no longer be eligible for the program
  • Federally funded commercial insurance plans are NOT eligible
  • Enrollment period is for 12 months; after that you will be re-evaluated for continued eligibility for the program
  • Alcresta Therapeutics reserves the right to rescind, revoke, amend, or terminate this program at any time
  • This program is not health insurance
  • By using this out-of-pocket financial assistance benefit, you acknowledge and attest that you currently meet the eligibility criteria and will comply with the program terms and conditions
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Patient Assistance Program

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 1-844-632-9271. 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 Enrollment Form

Email or fax the completed documentation to RelizorbOrder@asembia.com or 1-844-233-3146

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