Patient Assistance Information


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Patient Assistance Information

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15 Programs Sponsored By Genentech, Inc. (External Link)


Genentech Access to Care Foundation (Lucentis)
PO Box 2807 San Francisco, CA 94083 Phone : 800-232-0592 Fax: 888-727-7773
Eligibility
>	This program is intended for patients with no prescription coverage or have been denied coverage. Medicare PartD is determined case by case. Gross annual household income at or below $100,000. Must be treated by US licensed healthcare provider
Who Can Apply
>	Doctor/Doctor's office starts process by filling out enrollment/statement of medical necessity forms. Application is received via fax, mail or download from website. Return application via fax or mail.
Required
>	Diagnosis/Medical Criteria not disclosed. Doctor must complete and sign statement of medical necessity. Patient must complete Patient Authorization and Notice of Information Form available on website, attach proof of income.
Supply
>	Amount/supply varies. Refill process and limit not specified. New application is to be completed yearly.
Ship To
>	Ship to Doctor's office, hospital, or pharmacy.
Note
>	This program also provides copay assistance. Contact program for Spanish application.

Includes Support for This Drug NOTE: Linked drugs are available for Prescribers to Apply Online now. Click drug logo or drug name to start online application.
Lucentis Injection


Genentech Access to Care Foundation (Avastin, Herceptin, Rituxan, Tarceva)
PO Box 2807 South San Francisco, CA 94083 Phone : (888)249-4918 Fax: (888)249-4919
Eligibility
>	Must have no prescription coverage or been denied coverage. Medicare partD is determined case by case. Gross annual household income at or below $100,000. Must be treated by US licensed healthcare provider.
Who Can Apply
>	Doctor/Doctor's office starts process by filling out Statement of Medical Necessity Form. Application can be faxed mailed or downloaded from website and returned via fax or mail/.
Required
>	Diagnosis/Medical Criteria not disclosed. Doctor must complete and sign statement of medical necessity. Patient must complete Patient Authorization and Notice of Information Form available on website and attach proof of income.
Supply
>	Amount/supply varies. Refill process and limit not specified. New application must be completed yearly.
Ship To
>	Sent to Doctor's office, hospital, or pharmacy.
Note
>	Rituxan NHL: Non-Hodgkins Lymphoma Rituxan CLL: Chronic Lymphocytic Leukemia

Includes Support for This Drug NOTE: Linked drugs are available for Prescribers to Apply Online now. Click drug logo or drug name to start online application.
Avastin vial; intravenous
Herceptin vial; iv
Rituxan injection (nhl & cll)


Genentech Access to Care Foundation (Pulmozyme)
PO Box 2807 South San Francisco, CA 94083 Phone : 800-690-3023 Fax: (800)704-6612
Eligibility
>	patient must have no prescription coverage or been denied coverage. Medicare partD determined case by case. Gross annual household income at or below $100,000. Must be treated by US licensed healthcare provider.
Who Can Apply
>	The doctor/doctors office starts the process by filling out the enrollment/statement of medical necessity form. Application can be faxed, mailed or downloaded from website and returned via fax or mail.
Required
>	Doctor must complete and sign statement of medical necessity. Patient must complete patient authorization and notice of information form available on website and attach proof of income.
Supply
>	Amount/supply varies. Refill process and limit not specified. New application to be completed yearly.
Ship To
>	Ship to patient's home, doctor's office, hospital or pharmacy.
Note
>	This is a program for cystic fibrosis patients who are first-time users of Pulmozyme with an on-label diagnosis, or previous users of the medication who are re-initiating therapy and have an on-label diagnosis. The company will offer benefits investigation and copay assistance as well.

Includes Support for This Drug NOTE: Linked drugs are available for Prescribers to Apply Online now. Click drug logo or drug name to start online application.
Pulmozyme vial

Printable Application Forms Applications that patients can fill out and bring to their doctor.
Download printable Form Application Form
Download printable Form Genentech Access to Care Foundation (Pulmozyme)
(Requires Acrobat Reader)


Genentech Access to Care Foundation (Nutropin)
Nutropin GPS PO Box 220039 Charlotte, NC 28222 Phone : 866-688-7674 Fax: 800-545-0612
Eligibility
>	This program is intended for patients with no prescription coverage or have been denied coverage. Medicare PartD determined case by case. Gross annual household income at or below $100,000. Must be treated by US licensed healthcare provider.
Who Can Apply
>	Doctor/Doctor's office starts process by filling out enrollment/statement of medical necessity forms. Application can be received via fax, mail or download from website. Return application via fax or mail. Patient will be notified of decision.
Required
>	Diagnosis/Medical Criteria not disclosed. Doctor must complete and sign statement of medical necessity. Patient must complete Patient Authorization and Notice of Information Form available on website, attach proof of income.
Supply
>	Amount/supply varies. Patient must contact company for refills. No refill limit. New application must completed yearly.
Ship To
>	Ship to Doctor's office or patient's home within 2 business days.
Note
>	Eligibility determined on a case-by-case basis. Negative decision may be appealed. Appeal letter templates can be found on the program website.

Includes Support for This Drug NOTE: Linked drugs are available for Prescribers to Apply Online now. Click drug logo or drug name to start online application.
Nutropin AQ NuSpin Pen pen
Nutropin AQ Pen pen

Printable Application Forms Applications that patients can fill out and bring to their doctor.
Download printable Form Genentech Access to Care Foundation (Nutropin)
(Requires Acrobat Reader)


Genentech Access to Care Foundation (TNKase, Cathflo, Activase)
1 DNA Way Mail Stop 210 South San Francisco, CA 94080 Phone : 800-530-3083 Fax: (800)704-6615
Eligibility
>	This is program is intended for uninsured patients. Medicare PartD not eligible. Gross annual household income at or below $100,000. Must be treated by US licensed healthcare provider
Who Can Apply
>	Doctor/Doctor's office starts process by filling out enrollment/statement of medical necessity forms. Application can be received via fax, mail or download from website. Return application via fax or mail. Doctor will be notified of decision.
Required
>	Diagnosis/Medical Criteria not disclosed. Doctor must complete and sign the application and attach a letter of medical necessity. Patient must complete Patient Authorization and Notice of Information Form available on website and attach proof of income.
Supply
>	Amount supply varies. Refill process and limit varies. New application must be completed yearly.
Ship To
>	Ship to Doctor's office, hospital, or pharmacy.
Note
>	Please visit www.Activase.com, www.Cathflo.com & www.TNKase.com for more information.

Includes Support for This Drug NOTE: Linked drugs are available for Prescribers to Apply Online now. Click drug logo or drug name to start online application.
Activase vial
Cathflo Injection
TNKase vial

Printable Application Forms Applications that patients can fill out and bring to their doctor.
Download printable Form Genentech Access to Care Foundation (TNKase, Cathflo, Activase)
(Requires Acrobat Reader)


Genentech Access to Care Foundation (Xolair)
PO Box 2807 South San Francisco, CA 94083 Phone : 800-704-6614 Fax: 800-704-6612
Eligibility
>	This program is intended for patients with no prescription coverage or who have been denied coverage. Medicare PartD determined case by case. Gross annual household income at or below $100,000. Must be treated by US licensed healthcare provider.
Who Can Apply
>	Doctor/Doctor's office starts process by filling out enrollment/statement of medical necessity forms. Application received via fax, mail or download from website. Return application via fax or mail.
Required
>	Diagnosis/Medical Criteria not disclosed. Doctor must complete and sign statement of medical necessity. Patient must complete Patient Authorization and Notice of Information Form available on website, attach proof of income.
Supply
>	Amount/supply varies. Refill process & limit not specified. Re-application must be completed yearly.
Ship To
>	Ship to Doctor's office, hospital, or pharmacy.
Note
>	Insurance benefits, claims assistance and/or other reimbursement help is offered.

Includes Support for This Drug NOTE: Linked drugs are available for Prescribers to Apply Online now. Click drug logo or drug name to start online application.
Xolair vial

Printable Application Forms Applications that patients can fill out and bring to their doctor.
Download printable Form Genentech Access to Care Foundation (Xolair)
(Requires Acrobat Reader)


Genentech Access to Care Foundation (Actemra, Rituxan)
1 DNA Way Mail Stop 857A South San Francisco, CA 94080 Phone : (866)681-3329 Fax: (866)681-3329
Eligibility
>	This is program is intended for patients with no prescription coverage or have been denied coverage. Medicare PartD determined case by case. Gross annual household income at or below $100,000. Must be treated by US licensed healthcare provider.
Who Can Apply
>	Doctor/Doctor's office starts process by filling out enrollment/statement of medical necessity forms. Application received via fax, mail or download from website. Return application via fax or mail.
Required
>	Diagnosis/Medical Criteria not disclosed. Doctor must complete and sign statement of medical necessity.
Supply
>	Amount/Supply varies. Refill process and limit not specified. New application must be completed yearly. Patient must complete Patient Authorization and Notice of Information Form available on website, attach proof of income.
Ship To
>	Ship to Doctor's office, hospital, or pharmacy.
Note
>	Rituxan RA: Rheumatoid Arthritis Rituxan MPA: Microscopic Polyangilitis Rituxan GPA: Granulomatosis with Polyangilits (Formerly known as Wegener’s Granulomatosis)

Includes Support for This Drug NOTE: Linked drugs are available for Prescribers to Apply Online now. Click drug logo or drug name to start online application.
Actemra injection
Rituxan injection (ra, gpa & mpa)


Genentech Access to Care Foundation (HIV & Transplants)
PO Box 29064 Phoenix, AZ 85038 Phone : (888)754-7651 Fax: (800)305-1830
Eligibility
>	This program is intended for patients with no prescription coverage or been denied coverage. Medicare PartD determined case by case. Gross annual household income at or below $100,000. Must be treated by US licensed healthcare provider.
Who Can Apply
>	Doctor/Doctor's office starts process by filling out Statement of Medical Necessity Form. Application can be received via fax, mail, or download from website. Return application via fax or mail.
Required
>	Diagnosis/Medical Criteria not disclosed. Doctor must complete and sign statement of medical necessity. Patient must complete Patient Authorization and Notice of Information Form available on website, attach proof of income.
Supply
>	Amount/supply varies. Refill process and limit not specified. New application is to be completed yearly.
Ship To
>	Ship to Patient's home, doctor's office, hospital or pharmacy.
Note
>

Includes Support for This Drug NOTE: Linked drugs are available for Prescribers to Apply Online now. Click drug logo or drug name to start online application.
Cellcept capsule
Cellcept oral suspension
Cellcept tablet
Valcyte oral solution
Valcyte tablet

Printable Application Forms Applications that patients can fill out and bring to their doctor.
Download printable Form Genentech Access to Care Foundation (HIV & Transplants)
(Requires Acrobat Reader)


Genentech Access to Care Foundation (Cotellic & Zelboraf)
PO Box 2807 South San Francisco, CA 94083 Phone : (888)249-4918 Fax: (877)313-2659
Eligibility
>	This program is intended for patients with no prescription coverage or have been denied coverage. Medicare PartD determined case by case. Gross annual household income at or below $100,000. Must be treated by US licensed healthcare provider.
Who Can Apply
>	Doctor/Doctor's office starts process by filling out enrollment/statement of medical necessity forms. Application can be received via fax, mail or downloaded from website. Return application via fax or mail.
Required
>	Diagnosis/Medical Criteria not disclosed. Doctor must complete and sign statement of medical necessity. Patient must complete Patient Authorization and Notice of Information Form available on website, attach proof of income.
Supply
>	Amount/supply varies. Refill process and limit not specified. New application is to be completed yearly.
Ship To
>	Ship to Patient's home, doctor's office, hospital or pharmacy.
Note
>

Includes Support for This Drug NOTE: Linked drugs are available for Prescribers to Apply Online now. Click drug logo or drug name to start online application.
Cotellic
Zelboraf tablet


Genentech Access to Care Foundation (Erivedge)
PO Box 2807 South San Francisco, CA 94083 Phone : (888)249-4918 Fax:
Eligibility
>	This program is intended for Patients with no prescription coverage for needed medication. Medicare PartD determined case by case. Gross annual household income at or below $100,000. Must be treated by US licensed healthcare provider.
Who Can Apply
>	Doctor/Doctor's office starts process by filling out Statement of Medical Necessity Form. Application received via fax, mail, or downloaded from website. Return application via fax or mail. Patient will be notified of decision.
Required
>	Diagnosis/Medical Criteria not disclosed. Doctor must complete and sign statement of medical necessity. Patient must complete Patient Authorization and Notice of Information Form available on website, attach proof of income.
Supply
>	Amount/supply varies. Refill process and limit not specified. New application must be completed yearly.
Ship To
>	Ship to Patient's home, doctor's office, hospital or pharmacy.
Note
>

Includes Support for This Drug NOTE: Linked drugs are available for Prescribers to Apply Online now. Click drug logo or drug name to start online application.
Erivedge capsule

Printable Application Forms Applications that patients can fill out and bring to their doctor.
Download printable Form Genentech Access to Care Foundation (Erivedge)
(Requires Acrobat Reader)


Genentech Access to Care Foundation (Tarceva)
PO Box 2807 South San Francisco, CA 94083 Phone : (888)249-4918 Fax: (888)249-4919
Eligibility
>	This program is intended for patients with no prescription coverage or been denied coverage. Medicare PartD determined case by case. Gross annual household income at or below $100,000. Must be treated by US licensed healthcare provider.
Who Can Apply
>	Doctor/Doctor's office starts process by filling out Statement of Medical Necessity Form. Application can be received via fax, mail, or downloaded from website. Return application via fax or mail.
Required
>	Diagnosis/Medical Criteria not disclosed. Doctor must complete and sign statement of medical necessity. Patient must complete Patient Authorization and Notice of Information Form available on website, attach proof of income.
Supply
>	Amount/supply varies. Refill process and limit not specified. New application is to be completed yearly.
Ship To
>	Ship to Patient's home, doctor's office, hospital or pharmacy.
Note
>

Includes Support for This Drug NOTE: Linked drugs are available for Prescribers to Apply Online now. Click drug logo or drug name to start online application.
Tarceva tablet

Printable Application Forms Applications that patients can fill out and bring to their doctor.
Download printable Form Genentech Access to Care Foundation (Tarceva)
(Requires Acrobat Reader)


Genentech Access to Care Foundation (Perjeta)
PO Box 2807 South San Francisco, CA 94083 Phone : (888)249-4918 Fax: (888)249-4919
Eligibility
>	This program is intended for patients with no prescription coverage or been denied coverage. Medicare PartD is determined case by case. Gross annual household income at or below $100,000. Must be treated by US licensed healthcare provider.
Who Can Apply
>	Call or download application from website. Return application via fax.
Required
>	Diagnosis/Medical Criteria not disclosed. Doctor must complete and fax Statement of Medical Necessity and signed Patient Authorization forms which are on the website. Patient must complete section, sign, attach proof of income.
Supply
>	Amount/supply varies. Refill process and limit not specified. New application is to be completed yearly.
Ship To
>	Ship to Doctor's office, hospital, or pharmacy.
Note
>

Includes Support for This Drug NOTE: Linked drugs are available for Prescribers to Apply Online now. Click drug logo or drug name to start online application.
Perjeta vial; single-use

Printable Application Forms Applications that patients can fill out and bring to their doctor.
Download printable Form Genentech Access to Care Foundation (Perjeta)
(Requires Acrobat Reader)


Genentech Access to Care Foundation (Kadcyla)
PO Box 2807 South San Francisco, CA 94083 Phone : (888)249-4918 Fax: (888)249-4919
Eligibility
>	Insurance requirements are determined case by case, this includes Medicare PartD patients. Gross annual household income at or below $100,000. Must be treated by US licensed healthcare provider.
Who Can Apply
>	Doctor/Doctor's office starts process by filling out enrollment/statement of medical necessity forms. Application received via fax, mail or downloaded from website. Return application via fax or mail.
Required
>	Diagnosis/Medical Criteria not disclosed. Doctor must complete and sign statement of medical necessity. Patient must complete Patient Authorization and Notice of Information Form.
Supply
>	Amount/supply varies. Refill process and limit not specified. New application must be completed yearly.
Ship To
>	Ship to Doctor's office, hospital, or pharmacy.
Note
>

Includes Support for This Drug NOTE: Linked drugs are available for Prescribers to Apply Online now. Click drug logo or drug name to start online application.
Kadcyla vial; single-use

Printable Application Forms Applications that patients can fill out and bring to their doctor.
Download printable Form Genentech Access to Care Foundation (Kadcyla)
(Requires Acrobat Reader)


Genentech Access to Care Foundation (Gazyva)
Genentech BioOncology Access Solutions 1 DNA Way, Mail Stop #858A South San Francisco, CA 94080 Phone : (888)249-4918 Fax: (888)249-4919
Eligibility
>	This program is intended for patients with no prescription coverage for needed medication. Medicare PartD not eligible. Gross annual household income at or below $100,000. No residency requirements.
Who Can Apply
>	Call or enroll online. Download application from website. Return application via fax or submit online.
Required
>	Medically appropriate condition/diagnosis is required. Doctor must complete and sign statement of medical necessity. Patient must complete Patient Authorization and Notice of Information Form.
Supply
>	Amount/supply not applicable. Refill process and limit not specified. Re-application process not specified.
Ship To
>	Not applicable at this time.
Note
>

Includes Support for This Drug NOTE: Linked drugs are available for Prescribers to Apply Online now. Click drug logo or drug name to start online application.
Gazyva injection

Printable Application Forms Applications that patients can fill out and bring to their doctor.
Download printable Form Genentech Access to Care Foundation (Gazyva)
(Requires Acrobat Reader)


Genentech Access to Care Foundation (Alecensa)
, Phone : (888)249-4918 Fax:
Eligibility
>	This program is intended for Patients with no prescription coverage or been denied coverage. Medicare PartD determined case by case. Gross annual household income at or below $100,000. Must be treated by US licensed healthcare provider.
Who Can Apply
>	Doctor/Doctor's office starts process by filling out enrollment/statement of medical necessity forms. Application received via fax, mail or download from website. Return application via fax or mail.
Required
>	Diagnosis/Medical Criteria not disclosed. Doctor must complete and sign statement of medical necessity. Patient must complete Patient Authorization and Notice of Information Form available on website, attach proof of income.
Supply
>	Amount/supply varies. Refill process and limit not specified. New application is to be completed yearly.
Ship To
>	Ship to Patient's home, doctor's office, hospital or pharmacy.
Note
>

Includes Support for This Drug NOTE: Linked drugs are available for Prescribers to Apply Online now. Click drug logo or drug name to start online application.
Alecensa

Printable Application Forms Applications that patients can fill out and bring to their doctor.
Download printable Form Genentech Access to Care Foundation (Alecensa)
(Requires Acrobat Reader)