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Updated April 24, 2014
Activase

Genentech Access to Care Foundation (TNKase, Cathflo, Activase)

This program provides brand name medications at no or low cost.

Provided by: Genentech, Inc.

1 DNA Way, Mail Stop 858A
South San Francisco, CA 94080

TEL: 800-530-3083


ALT PHONE: 800-704-6614
FAX: 800-704-6615
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website
 

Patient Assistance Applications

Genentech Access to Care Foundation (TNKase, Cathflo, Activase) Application

Genentech Access to Care Foundation (TNKase, Cathflo, Activase) Application (Spanish)

Genentech Access to Care Foundation: Statement of Medical Necessity; TNKase, Cathflo, Activase

Genentech Financial Attestation Form; TNKase, Cathflo, Activase

Genentech Confirmation of Infusion or Injection Form; Activase

Genentech Confirmation of Infusion or Injection Form; Cathflo

Genentech Confirmation of Infusion or Injection Form; TNKase

 

Medications

  • Activase Vial 50mg, 100mg (alteplase (rDNA))
 

Eligibility Requirements

Insurance Status Must have no prescription coverage or been denied coverage
Those with Part D Eligible? No
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/Doctors office starts process by filling out enrollment/statement of medical necessity forms
Receiving Faxed, mailed or downloaded from website
Returning Mail or fax
Doctor's Action Complete and sign the application and attach a letter of medical necessity
Applicant's Action Complete Patient Authorization and Notice of Information Form available on website, attach proof of income
Decision Communicated Doctor notified
Decision Timeframe Not specified
   

Medication

Amount/Supply Varies
Sent To Doctor's office, hospital, or pharmacy
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application New application yearly
   

Additional Information