Out-of-Pocket Assistance Program

The program is open to individuals who:

• Have commercial insurance
• Are prescribed RELiZORB

If You Qualify, Enrollment in the Program is Automatic

If you are eligible, you will be enrolled in the program when RELiZORB Support Services reviews your commercial insurance benefits. Enrollment in the program is subject to confirmation of eligibility.

How Much Could I Save?

All eligible patients will have no co-pay, co-insurance, or deductibles for their first four 30-count boxes of RELiZORB.

Alcresta Therapeutics will cover a maximum benefit of $6,720 for each calendar year.

There is no out-of-pocket assistance card required — your benefit will be automatically deducted from your bill.

Program Terms and Conditions

• This program covers the cost of RELiZORB out-of-pocket costs. Examples of the types of out-of-pocket expenses that are covered include co-payment, co-insurance, and/or deductibles
• Eligible patients must have a prescription for RELiZORB
• Eligible patients must have commercial insurance that covers RELiZORB
• Out-of-Pocket Assistance is limited to two 30-count boxes of RELiZORB per month, no exceptions
• Persons enrolled in any government healthcare program, such as Medicare, Managed Medicare, Medicaid, Managed Medicaid, Tricare, Triwest, and Veterans Administration are not eligible for the RELiZORB Out-of-Pocket Assistance Program
• All coverage requirements mandated by the insurance company of the eligible patient must be satisfied in order for the program to take effect
• Patients who move from commercial to federally funded insurance will no longer be eligible for the program
• Federally funded commercial insurance plans are NOT eligible
• Enrollment period is for 12 months; after that you will be re-evaluated for continued eligibility for the program
• Alcresta Therapeutics reserves the right to rescind, revoke, amend, or terminate this program at any time
• This program is not health insurance
• By using this out-of-pocket financial assistance benefit, you acknowledge and attest that you currently meet the eligibility criteria and will comply with the program terms and conditions