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Program 1 of 4.
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Genentech Patient Foundation

This program provides medication at no cost.

Provided by: Genentech USA, Inc.


TEL: 888-941-3331


FAX: 833-999-4363
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Genentech Patient Foundation Enrollment Form

 

Medications

  • Rituxan (rituximab)
 

Eligibility Requirements   

Insurance Status Uninsured or Underinsured with no prescription coverage for needed medication
Those with Part D Eligible? Contact program for details.
Income Income Guidelines published on Program Website
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must be treated by US licensed healthcare provider
   

Application

Obtaining Call or download
Receiving Faxed or downloaded from website
Returning Fax from Doctor's office
Doctor's Action Complete section and sign
Applicant's Action Complete section and sign
Decision Communicated Patient and Doctor are notified
Decision Timeframe Varies
   

Medication

Amount/Supply Amount requested is sent
Sent To Patient's home, unless otherwise noted
Delivery Time Varies
Refill Process Varies per medication
Limit Not specified
Re-application Not specified
   

Additional Information

The Genentech Access to Care Foundation is now the Genentech Patient Foundation.

Eligibility determined on a case-by-case basis.

Call for most recent medications as the list is subject to change.


Updated February 12, 2019


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

This program provides brand name medications at no or low cost

Provided by: Genentech USA, Inc.

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

TEL: 866-422-2377


FAX: 866-480-7762
Languages Spoken:

English, Spanish

Program Website

 

Program Applications and Forms

Genentech Patient Auth. and Notice of Request (PAN)

Genentech Patient Auth. and Notice of Request (PAN) (Spanish)

 

Medications

  • Rituxan (rituximab)
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Determined case by case
Income Based on FPL
Diagnosis/Medical Criteria Varies
US Residency Required? Must be treated by US licensed healthcare provider
   

Application

Obtaining Call, download or apply online
Receiving Faxed, emailed, mailed or downloaded
Returning Fax, mail or submit online (Note: faxed prescriptions are only valid if faxed directly from a prescriber's office)
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Patient or patient representative signs authorization form
Decision Communicated Patient and Doctor are notified
Decision Timeframe Varies
   

Medication

Amount/Supply Varies
Sent To Varies
Delivery Time Contact Program for Details
Refill Process Doctor/Doctor's office must contact company
Limit One year
Re-application Contact program for details.
   

Additional Information

Call for most recent medications as the list is subject to change.


Updated February 12, 2019


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

This is a copay assistance program

Provided by: HealthWell Foundation

P.O. Box 489
Buckeystown, MD 21717

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

  • Rituxan (rituximab)
 

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 January 16, 2019


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Patient Access Network Foundation (PAN)

This is a copay assistance program

Provided by: Patient Access Network Foundation


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

  • Rituxan (rituximab)
 

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 January 04, 2019