With the ZILRETTA Copay Assistance Program, you may be eligible to receive up to a $100 rebate for each ZILRETTA injection* if you:
- Have a private insurance plan that covers the medication costs of ZILRETTA
- Are not covered by any federal- or state-funded health care programs, such as Medicare, Medicaid, Medicare Advantage, or TRICARE
*This rebate covers out-of-pocket copay or coinsurance costs for ZILRETTA. It does not apply to your deductible, administrative, or office visit costs.
3 Simple steps to help you save on ZILRETTA
COMPLETE this application form.
If you’re unsure about any of the fields in the Prescriber Information section, ask your doctor’s office for help.
Make a copy of your Explanation of Benefits (EOB) or itemized Specialty Pharmacy receipt to submit with your application form.
Fax or mail the completed form and a copy of your EOB or itemized Specialty Pharmacy receipt:
Mail: The ZILRETTA Copay Assistance Program 2250 Perimeter Park Drive, Suite 300 Morrisville NC 27560
Be sure to sign and date the form before submitting.
Frequently Asked Questions
I submitted my application form, how do I know I'm eligible?
If eligible, you’ll receive a letter or fax updating you on the status of your rebate.
What is an Explanation of Benefits (EOB)?
An EOB is a statement from your insurance plan that explains the cost that it will cover for your treatment.
How do I obtain an EOB?
An EOB is created when your doctor submits a claim for your treatment and you will usually receive it within 2-3 weeks after your injection.
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, Medicare Advantage, 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 copay- or coinsurance-related 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.