Follow these simple steps to enroll your patients

1
Give your patients the ZILRETTA Copay Assistance Program Patient Application form.
DOWNLOAD Application form

2
Have your patient complete the required fields and sign and date the form. Remind your patient to make a copy of the Explanation of Benefits (EOB) or itemized Specialty Pharmacy receipt for ZILRETTA and submit the copy with the completed form.

3
Instruct your patient to fax or mail the form when complete.

Mail: The ZILRETTA Copay Assistance Program

2250 Perimeter Park Drive, Suite 300

Morrisville, NC 27560

Fax: 1-855-915-3006

Eligible patients will receive a letter or fax informing them that they can receive up to a $100 rebate on their ZILRETTA injection. To receive the rebate, patients will need to send a copy of their EOB or itemized Specialty Pharmacy receipt for ZILRETTA along with the completed application form. Your office will be notified by mail or fax when your patient is approved for the rebate.

Copay Eligibility

Patients may be eligible if they:

  • Have private insurance plan that covers the medication costs of ZILRETTA
  • Are not covered by any federal- or state-funded healthcare programs, such as Medicare, Medicaid, or TRICARE
  • Live in the United States, Puerto Rico, or United States Territories

Please note that this rebate only covers out-of-pocket copay or coinsurance costs for ZILRETTA and does not cover administrative costs, office visit costs, or deductibles.

To learn more about the ZILRETTA Copay Assistance Program, call 1-844-248-7732.

The ZILRETTA Copay Assistance Program Terms and Conditions

Patient must have commercial health insurance that covers the medication costs of ZILRETTA. 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, TRICARE, a qualified health plan (QHP), Federal Employee Program (FEP), or any other federal or state healthcare plan, including pharmaceutical assistance programs, or where prohibited by law. The ZILRETTA Copay Assistance Program covers ONLY the out-of-pocket cost of ZILRETTA, up to an annual maximum dollar limit. The ZILRETTA Copay Assistance Program does not cover administrative or office visit costs. Cash patients are not eligible for this offer. Patient is responsible for reporting receipt of copay 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 Copay Assistance Program is available for patients residing in the US, Puerto Rico, or US Territories. Flexion Therapeutics reserves the right at any time and for any reason, without notice, to modify or discontinue any service or assistance provided through the Copay Assistance Program.

* Based on FlexForward’s database of 6,075 commercially covered patients from October 2020 to March 2021, 93% of patients had out-of-pocket drug-related costs of <$150 (~65% paying <$100 and ~28% paying $100-<$150), with the ZILRETTA Copay Assistance Program reimbursing up to $100 for eligible patients.1

This program is not available to individuals enrolled in federal- or state-subsidized healthcare programs that cover prescription drugs, including Medicare, such as Medicare Part D prescription drug benefit, Medicaid, Medicare Advantage, TRICARE, or any other federal or state healthcare plan, including pharmaceutical assistance programs.