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Patient Assistance Information

 
 
 
Genentech Access to Care Foundation (Erivedge)

PO Box 2807
South San Francisco, CA 94083
Phone : (888)249-4918
Fax:
Eligibility
> This program is intended for Patients with no prescription coverage for needed medication. 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 Statement of Medical Necessity Form. Application received via fax, mail, or downloaded 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. Refill process and limit not specified. New application must be completed yearly.
Ship To
> Ship to Patient's home, 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.
 
Erivedge capsule
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Genentech Access to Care Foundation (Erivedge)
(Requires Acrobat Reader