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Patient Assistance Information

 
1 Program for Avastin vial; intravenous
 
 
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