Patient Information

* Required Fields

*Patient First Name

Enter Patient First Name

*Patient Last Name

Enter Patient Last Name

*Patient Date of Birth

Enter Patient Date of Birth/Patients under 18 years of age are not eligible

*Patient Gender

Select Patient Gender

*Patient Home Address Line 1

Enter Home Address Line 1

Patient Home Address Line 2

Enter Valid Address Line 2

*Patient City

Enter Patient City

*Patient State

Select Patient State

*Patient ZIP Code

Enter Patient ZIP Code

Patient Mobile Number

Enter Valid Phone

Patient Email

Enter Valid Email

Pharmacist please answer on behalf of patient:

I have appropriate authorization to enroll the patient in the ZILRETTA Co-Pay Program and share patient’s information disclosed during the enrollment, including name, e-mail address, and phone number, the sponsor of the Program as well as parties working on behalf of Pacira Biosciences, Inc. The information shared will include the date that the patient filled the prescription, specifics about the medication dispensed by the pharmacist, and the out-of-pocket costs under the Program. I understand that, for the purposes of administering the Program, patients, practices, and pharmacies participating in the Program may be contacted by the Program administrator to relay status or related matters. Program participation can be discontinued at any time by calling 844-733-1330.

Yes

Pharmacist must answer Yes for patient to be eligible for Program.

Reminder - this is for internal use only.

Pharmacist: When you apply this offer, you are certifying that you have not submitted a claim for reimbursement under any federal, state, or other governmental programs for this prescription. Participation in this Program must comply with all applicable laws and regulations as a pharmacy provider. By participating in this Program, you are certifying that you will comply with the terms and conditions described in the Terms and Conditions section below.

ZILRETTA CO-PAY PROGRAM TERMS & CONDITIONS

The ZILRETTA Co-Pay Program ("Program") helps commercially insured patients access treatment for little to no cost.
Patients certify that they understand the Program details, meet the eligibility criteria, and will comply with the Program’s complete Terms and Conditions available at www.zilretta.com/copay.
Patients must have commercial health insurance that covers the medication costs of ZILRETTA. Patients whose commercial health insurance does not cover the medication costs of Zilretta or patients without commercial health insurance (cash) are not eligible for this Program.
Patients are not eligible if prescriptions are paid, in whole or in part, by federal or state subsidized healthcare program that covers the cost of ZILRETTA, including Medicare, such as Medicare Part D prescription drug benefit, Medicaid, Medicare Advantage, TRICARE, a qualified health plan (QHP), Federal Employee Program (FEP), or any other federal or state healthcare plan, including pharmaceutical assistance program, or where prohibited by law.
The Patient, or his/her legal representative, or health care provider must enroll the patient in the ZILRETTA Co-Pay Program. Patient will be automatically re-enrolled in subsequent years after the initial enrollment period ends as long as the Patient still meets Program eligibility requirements.
Patient’s participation in this Program means that he/she is ensuring compliance with any required disclosure of Patient’s insurance carrier or pharmacy benefit manager regarding HCP’s and Patient’s participation in the ZILRETTA Co-Pay Program. Patient is responsible for reporting receipt of co-pay assistance to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled, as may be required.
The ZILRETTA Co-Pay Program covers ONLY the related out of pocket cost of ZILRETTA, up to an annual maximum dollar limit.
The ZILRETTA Co-Pay Program does not cover administrative or office visit costs.
Patient must have received an on-label diagnosis for ZILRETTTA from their HCP to be eligible for the ZILRETTA Co-Pay Program.
The ZILRETTA Co-Pay Program is available for patients permanently residing in the US, Puerto Rico, or US Territories 18 years of age or older.
ZILRETTA is dispensed pursuant to Program rules, and federal and state laws. Pacira BioSciences, Inc. reserves the right to rescind revoke, amend or terminate the Program at any time and for any reason, without notice.

Program Benefits

Patient may be eligible to pay as little as $0 out of pocket per prescription up to the maximum of $1,000 per calendar year
Additional Terms and Conditions of Program: Patients, pharmacists, and healthcare providers must not seek reimbursement from health insurance or any third party for any part of the benefit received by the patient through this Program. Patients must not seek reimbursement from any health savings, flexible spending, or any other healthcare reimbursement accounts for the amount of assistance received from the Program. This offer is not conditioned on any past, present, or future purchase, including additional treatments. This offer is not insurance.

Click here to see full Terms and Conditions.

THE ZILRETTA CO-PAY PROGRAM

SPECIALTY PHARMACY ENROLLMENT PROCESSING FORM

Patient Eligibility

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Patient Information

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SPECIALTY PHARMACY ENROLLMENT PROCESSING FORM

Patient Eligibility

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Patient Information

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Already Enrolled

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