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Patient Assistance Information

Genentech Access to Care Foundation (Cotellic & Zelboraf)

PO Box 2807
South San Francisco, CA 94083
Phone : (888)249-4918
Fax: (877)313-2659
> 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 downloaded from website. Return application via fax or mail.
> 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.
> Amount/supply varies. Refill process and limit not specified. New application is to be completed yearly.
Ship To
> Ship to Patient's home, doctor's office, hospital or pharmacy.
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.
Zelboraf tablet