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Genentech Access to Care Foundation (Alecensa)
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Phone
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(888)249-4918
Fax:
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Eligibility
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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
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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. |
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Required
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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. |
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Supply
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Amount/supply varies. Refill process and limit not specified. New application is to be completed yearly. |
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Ship To
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Ship to Patient's home, doctor's office, hospital or pharmacy. |
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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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| Alecensa |
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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 (Alecensa) |
(Requires Acrobat Reader) 
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