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
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.
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.
|Cardinal (Drug side)||5206982|
|Cardinal (Medical/Surgical side)||100295|
|McKesson (Drug side)||3507662|
|McKesson (Medical/Surgical side)||23564601|
|Morris & Dickson||245555|
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.
See how RELiZORB is helping a 17-year old student living with cystic fibrosis