Download Patient Enrollment Form for RELiZORB here
Getting your patient started with RELiZORB is easy. RELiZORB Support Services will be here every step of the way to help you, and to help your patient start and stay on RELiZORB under your direction.
What’s needed to enroll patients?
Two documents are required to make a patient eligible to receive RELiZORB. Please note that the Patient Enrollment Form can be sent to RELiZORB Support Services in 3 different ways:
Filling out the Patient Enrollment Form
You and your patient can work together to complete the Patient Enrollment Form; just follow these 2 easy steps:
Please see below for links to sample Letters of Medical Necessity to request approval for use of and subsequent payment for RELiZORB on behalf of your patient. Please note: one form is specific for patients with cystic fibrosis, the other is not. The prescriber must modify the sample letter to be appropriate for the particular patient as the prescriber deems appropriate in his or her professional discretion.
If you have a patient(s) that has been denied coverage for RELiZORB by their insurance company, you may find the “Common Payer Questions and Objections to Covering RELiZORB” document below useful. The document is intended to provide Physicians, Registered Dieticians, and other HCPs who treat patients, that may benefit from the inclusion of RELiZORB as part of an enteral nutrition regimen, with possible responses to questions and objections frequently expressed by insurers/payers in deciding whether to cover RELiZORB. This document is provided for informational purposes only and its use does not guarantee that reimbursement for RELiZORB for a particular patient will be obtained. This document is intended for use with insurers/payers only.
For hospitals ordering RELiZORB, refer to the information below.
RELiZORB is supplied in boxes of 30 cartridges: 1 box = 30 cartridges.
The RELiZORB NDC* is 62205000020, and the UDI is 00862205000243.
|Cardinal (Drug Side)||5206982|
|Cardinal (Medical/Surgical Side)||100295|
|Morris & Dickson||245555|
*Third-party-derived code based on UDI.
To order RELiZORB directly from Alcresta Therapeutics, please send your PO to the following email: GMB-SPS-ALCRESTA@cordlogistics.com. GPOs we currently contract with include Vizient, Intalere, and Premier. For pricing information outside those GPOs, or other hospital ordering related questions, please contact Hospital Order Support at 1-844-632-9271.
Effective January 1, 2019, RELiZORB has a permanent, separately billable Medicare billing code (B4105). In addition, RELiZORB was assigned the PE04 (Enteral and Equipment and/or Supplies) Product and Service Code, which may be relevant for certain patients under the July 11, 1984 Medicare National Coverage Determination for Enteral and Parenteral Nutritional Therapy (180.2).
Additional resources you may find helpful for implementing RELiZORB into your hospital:
Learn more about the benefits of RELiZORB from Jeanette Hasse, PhD, RD, LD, FADA, CNSC
For more information on how to order RELiZORB, contact RELiZORB Support Services at 1-844-632-9271.