Resources for healthcare professionals and practices

RELiZORB patient enrollment—outpatient and hospital discharge

For a patient to be eligible to receive RELiZORB, the Patient Enrollment Form and the Patient Authorization Form are needed. You and your patient (or their representative) can work together to complete the required forms; just follow these 3 easy steps:

Ask your patient (or their representative) to complete the Patient Authorization Form and sections 1 and 2 of the Patient Enrollment Form
You complete sections 3 through 6 of the Patient Enrollment Form
Submit both completed forms and supporting clinical documentation to RELiZORB Support Services by either emailing them to [email protected] or by faxing them to 1-844-233-3146

RELiZORB Patient Enrollment Form

RELiZORB Patient Authorization Form
Patient signing for themselves

RELiZORB Patient Authorization Form
Patient representative signing on behalf of patient

Helpful resources

The following resources are for use by healthcare professionals only. Depending on the individual patient you are treating, to help avoid delays in RELiZORB cartridge approval or to assist with managing a denial, the following materials may be helpful.

Clinical Documentation Checklist

Peer to Peer Preparation Guide

Cystic Fibrosis Patient
Letter of Medical Necessity Template

Non-Cystic Fibrosis Patient
Letter of Medical Necessity Template

Preparing Your Patient for Hospital Discharge

RELiZORB ordering information for hospitals

RELiZORB is supplied in boxes of 30 cartridges: 1 box = 30 cartridges. The RELiZORB NDC* is 62205000020, and the UDI is 00862205000243.

*Third-party-derived code based on UDI.

Distributor/GPO	Product/Contract Number
AmerisourceBergen	10177832
Cardinal (Drug side)	5206982
Cardinal (Medical/Surgical side)	100295
McKesson (Drug side)	3507662
McKesson (Medical/Surgical side)	23564601
Medline Industries	LCR205000243
Morris & Dickson	245555
Intalere/GPO	VH11821
Premier/GPO	PPPH21ALR01

To order RELiZORB directly from Alcresta Therapeutics

Please send your PO to the following email: [email protected]. GPOs we currently contract with include Intalere and Premier. For pricing information outside those GPOs, or other hospital ordering related questions, please contact Hospital Order Support at [email protected].

HCPCS billing code

Effective January 1, 2019, RELiZORB has a permanent, separately billable Medicare billing code (B4105). In addition, RELiZORB was assigned the PE04 (Enteral 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).

RELiZORB expert case study videos

In these videos, a team of clinical experts explore issues associated with fat malabsorption and how RELiZORB may help address these challenges in patients who require enteral feeding.