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Genentech Access to Care Foundation (Cotellic & Zelboraf)
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PO Box 2807
South San Francisco, CA 94083
Phone
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(888)249-4918
Fax:
(877)313-2659
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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. |
Who Can Apply
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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 downloaded 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 and limit not specified. New application is to be completed yearly. |
Ship To
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Ship to Patient's home, doctor's office, hospital or pharmacy. |
Note
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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. |
Cotellic |
Zelboraf tablet |
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