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Genentech Access to Care Foundation (Nutropin)
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Nutropin GPS
PO Box 220039
Charlotte, NC 28222
Phone
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866-688-7674
Fax:
800-545-0612
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Eligibility
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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. |
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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. |
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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. |
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Supply
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Amount/supply varies. Patient must contact company for refills. No refill limit. New application must completed yearly. |
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Ship To
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Ship to Doctor's office or patient's home within 2 business days. |
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Note
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Eligibility determined on a case-by-case basis. Negative decision may be appealed. Appeal letter templates can be found on the program website. |
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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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| Nutropin AQ NuSpin Pen pen |
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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 Genentech Access to Care Foundation (Nutropin) |
(Requires Acrobat Reader) 
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