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.

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

TEL: 844-735-4967


FAX: 844-890-1900
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

RELiZORB Patient Assistance Program Enrollment Form

RELiZORB Patient Assistance Program Order Form

RELiZORB Patient Guide

 

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 Fax or mail
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 Not specified
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Not specified
   

Additional Information


Updated July 21, 2017