Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 2.
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Genentech Access to Care Foundation (TNKase, Cathflo, Activase)

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: 800-530-3083


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

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

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 Patient 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

  • alteplase injection (Cathflo) Injection
  • alteplase vial (Activase) Vial
 

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 FDA-approved diagnosis
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 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

Please visit www.Activase.com, www.Cathflo.com & www.TNKase.com for more information.


Updated June 05, 2017


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

HealthWell Foundation Copay Program

This is a copay assistance program

Provided by: HealthWell Foundation

PO Box 220410
Chantilly, VA 20153-0410

TEL: 800-675-8416


FAX: 800-282-7692
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

HealthWell Foundation Copay Program: Contact program

 

Medications

  • alteplase () 
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Varies
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside in the US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified in writing
Decision Timeframe 3-5 business days
   

Medication

Amount/Supply Not applicable
Sent To Varies
Delivery Time Not specified
Refill Process Good for one year
Limit Not specified
Re-application New application every 12 months
   

Additional Information

This program provides financial assistance to eligible individuals to cover coinsurance, copayments, healthcare premiums and deductibles for certain treatments. Also, for those who are eligible for health insurance, but cannot afford the insurance premium, the foundation may be able to help by paying some or all of the medical portion of insurance premiums. The patient is being treated for a specific disease for which funding is available and has insurance that covers the treatment for this disease.

Call for most recent medications as the list is subject to change.
Updated May 22, 2017