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Genentech Access to Care Foundation (Pulmozyme)
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PO Box 2807
South San Francisco, CA 94083
Phone
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800-690-3023
Fax:
(800)704-6612
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Eligibility
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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
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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. |
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Required
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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. |
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Supply
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Amount/supply varies. Refill process and limit not specified. New application to be completed yearly. |
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Ship To
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Ship to patient's home, doctor's office, hospital or pharmacy. |
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Note
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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. |
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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.
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| Pulmozyme vial |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form Application Form |
| Download printable Form Genentech Access to Care Foundation (Pulmozyme) |
(Requires Acrobat Reader) 
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