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Patient Assistance Information

 
 
 
Genentech Access to Care Foundation (Gazyva)

Genentech BioOncology Access Solutions
1 DNA Way, Mail Stop #858A
South San Francisco, CA 94080
Phone : (888)249-4918
Fax: (888)249-4919
Eligibility
> This program is intended for patients with no prescription coverage for needed medication. Medicare PartD not eligible. Gross annual household income at or below $100,000. No residency requirements.
Who Can Apply
> Call or enroll online. Download application from website. Return application via fax or submit online.
Required
> Medically appropriate condition/diagnosis is required. Doctor must complete and sign statement of medical necessity. Patient must complete Patient Authorization and Notice of Information Form.
Supply
> Amount/supply not applicable. Refill process and limit not specified. Re-application process not specified.
Ship To
> Not applicable at this time.
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.
 
Gazyva injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Genentech Access to Care Foundation (Gazyva)
(Requires Acrobat Reader