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


FAX: 844-233-3146
Languages Spoken:

English, Spanish

Program Website

 

Patient Assistance Applications

RELiZORB Patient Enrollment Form

 

Brand Name Medications Covered

 
  • Relizorb cartridge
 

Generic Name

 
  • immobilized lipase cartridge
 

Eligibility Requirements   

Insurance Status Must be uninsured or underinsured
Those with Part D Eligible? No
Income Determined case by case
Diagnosis/Medical Criteria Medically Necessary as determined by a Doctor
US Residency Required? Must reside in the US
   

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 Patient and Doctor are notified
Decision Timeframe Varies
   

Medication

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

Additional Information

This program also provides copay assistance.


Updated September 27, 2018