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Genentech Access to Care Foundation (Actemra)

This program provides brand name medications at no or low cost

Provided by: Genentech, Inc.

Genentech Access Solutions
1 DNA Way, Mail Stop #858a
South San Francisco, CA 94080-4990

TEL: 866-422-2377


ALT PHONE: 866-681-3261
FAX: 866-681-3288
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Genentech Patient Auth. and Notice of Release of Information (PAN) Actemra

Genentech Patient Auth. and Notice of Release of Information (PAN): Actemra (Spanish)

Genentech Statement of Medical Necessity: Actemra

 

Medications

  • Actemra injection (tocilizumab)
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage or been denied coverage
Those with Part D Eligible? Determined case by case
Income Gross annual household income at or below $100,000
Diagnosis/Medical Criteria Not disclosed
US Residency Required? Must be treated by US licensed healthcare provider
   

Application

Obtaining Doctor/Doctor's office starts process by filling out enrollment/statement of medical necessity forms
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
Doctor's Action Complete and sign statement of medical necessity
Applicant's Action Complete Patient Authorization and Notice of Information Form available on website, attach proof of income
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Varies
Sent To Varies
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application New application yearly
   

Additional Information


Updated June 01, 2017


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 2.
 

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Patient Access Network Foundation (PAN)

This is a copay assistance program

Provided by: Patient Access Network Foundation

PO Box 221858
Charlotte, NC 28222-1858

TEL: 866-316-7263


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Patient Access Network Foundation (PAN) Application: Contact program

 

Medications

  • Actemra (tocilizumab)
 

Eligibility Requirements   

Insurance Status *See Additional Information section below
Those with Part D Eligible? Determined case by case
Income Between 400-500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Complete online or by phone
Returning Complete online or by phone
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Call for information or inform doctor that he/she is in need
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved; shipped same day
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months
   

Additional Information

*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.

Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.

Note: All new enrollment is now done electronically or over the phone. Contact program for details.


Updated June 29, 2017