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Genentech Access to Care Foundation (Xolair)
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PO Box 2807
South San Francisco, CA 94083
Phone
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800-704-6614
Fax:
800-704-6612
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Eligibility
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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
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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
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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
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Amount/supply varies. Refill process & limit not specified. Re-application must be completed yearly. |
Ship To
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Ship to Doctor's office, hospital, or pharmacy. |
Note
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Insurance benefits, claims assistance and/or other reimbursement help is offered. |
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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. |
Xolair vial |
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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)
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