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Patient Assistance Information

 
1 Program for Nutropin AQ Pen pen
 
 
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 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