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

Genentech Access to Care Foundation (Avastin)

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: 888-249-4918
FAX: 888-249-4919
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

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

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

Genentech Statement of Medical Necessity: Avastin

 

Brand Name Medications Covered

 
  • Avastin vial; intravenous
 

Generic Name

 
  • bevacizumab vial; intravenous
 

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 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 26, 2017