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

Genentech Access to Care Foundation (Alecensa)

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
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Patient Assistance Applications

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

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

Genentech Statement of Medical Necessity: Alecensa

 

Brand Name Medications Covered

 
  • Alecensa
 

Generic Name

 
  • alectinib
 

Eligibility Requirements   

Insurance Status Uninsured or Underinsured
Those with Part D Eligible? Determined case by case
Income Household income at or less than $150,000
Diagnosis/Medical Criteria Not applicable
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 Email, fax, mail or submit online
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 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

This program also provides copay assistance.


Updated October 15, 2018