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Patient Assistance Information

 
 
 
Genentech Access to Care Foundation (Pulmozyme)

PO Box 2807
South San Francisco, CA 94083
Phone : 800-690-3023
Fax: (800)704-6612
Eligibility
> patient must have 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
> The doctor/doctors office starts the process by filling out the enrollment/statement of medical necessity form. Application can be faxed, mailed or downloaded from website and returned via fax or mail.
Required
> Doctor must complete and sign statement of medical necessity. Patient must complete patient authorization and notice of information form available on website and attach proof of income.
Supply
> Amount/supply varies. Refill process and limit not specified. New application to be completed yearly.
Ship To
> Ship to patient's home, doctor's office, hospital or pharmacy.
Note
> This is a program for cystic fibrosis patients who are first-time users of Pulmozyme with an on-label diagnosis, or previous users of the medication who are re-initiating therapy and have an on-label diagnosis. The company will offer benefits investigation and copay assistance as well.
 
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.
 
Pulmozyme vial
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
Download printable Form Genentech Access to Care Foundation (Pulmozyme)
(Requires Acrobat Reader