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 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 Prescriber Form

Genentech Patient Foundation Patient Consent Form

 

Medications

  • alteplase vial (Activase) Vial
 

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, submit online, or send text image
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 September 10, 2020


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 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 Enrollment: Contact program

HealthWell Foundation COVID-19 Ancillary Costs: Contact program

 

Medications

  • alteplase () 
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Varies
Diagnosis/Medical Criteria FDA Approved Diagnosis - See Program Website for Details
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 July 20, 2020