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Patient Assistance Information

 
1 Program for Perjeta vial; single-use
 
 
Genentech Access to Care Foundation (Perjeta)

PO Box 2807
South San Francisco, CA 94083
Phone : (888)249-4918
Fax: (888)249-4919
Eligibility
> This program is intended for patients with 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
> Call or download application from website. Return application via fax.
Required
> Diagnosis/Medical Criteria not disclosed. Doctor must complete and fax Statement of Medical Necessity and signed Patient Authorization forms which are on the website. Patient must complete section, sign, attach proof of income.
Supply
> Amount/supply varies. Refill process and limit not specified. New application is to be completed yearly.
Ship To
> Ship to Doctor's office, hospital, or pharmacy.
Note
>
 
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.
 
Perjeta vial; single-use
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Genentech Access to Care Foundation (Perjeta)
(Requires Acrobat Reader