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Patient Assistance Information

Genentech Access to Care Foundation (Alecensa)

Phone : (888)249-4918
> This program is intended for Patients with no prescription coverage or 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 received via fax, mail or download 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.
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form Genentech Access to Care Foundation (Alecensa)
(Requires Acrobat Reader