Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
 

RELiZORB Patient Assistance Program

Provided by: Alcresta Therapeutics, Inc.


TEL: 844-632-9271


ALT PHONE: 844-735-4967
FAX: 844-233-3146
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

RELiZORB Patient Enrollment Form

RELiZORB Letter of Medical Necessity (Sample Letter)

 

Brand Name Medications Covered

 
  • Relizorb cartridge
 

Generic Name

 
  • immobilized lipase cartridge
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage for needed product
Those with Part D Eligible? No
Income Determined case by case
Diagnosis/Medical Criteria Medically Necessary as determined by a Doctor
US Residency Required? Not specified
   

Application

Obtaining Call or download
Receiving Faxed or downloaded from website
Returning Email or fax
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Not specified
Decision Timeframe Varies
   

Medication

Amount/Supply Varies
Sent To Patient's home, unless otherwise noted
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Not specified
   

Additional Information

This program also provides copay assistance.


Updated March 16, 2018