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Genentech Access to Care Foundation (Gazyva)
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Genentech BioOncology Access Solutions
1 DNA Way, Mail Stop #858A
South San Francisco, CA 94080
Phone
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(888)249-4918
Fax:
(888)249-4919
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Eligibility
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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
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Call or enroll online. Download application from website. Return application via fax or submit online. |
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Required
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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. |
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Supply
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Amount/supply not applicable. Refill process and limit not specified. Re-application process not specified. |
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Ship To
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Not applicable at this time. |
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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.
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| Gazyva injection |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form Genentech Access to Care Foundation (Gazyva) |
(Requires Acrobat Reader) 
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