Program Details
GENENTECH, INC
Genentech Patient Foundation
Xeloda
(capecitabine)
|
| CONTACT
INFO |
|
| Address: |
, |
| Phone: |
1-888-941-3331 |
Provider Phone: |
|
| Fax: |
1-833-999-4363 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Eligibility is determined on a case-by-case basis.
Patient must be uninsured or underinsured with no prescription coverage for needed medication. |
| Income at or below: |
Single |
$75,000 |
% FPL |
| |
Couple |
$100,000 |
% FPL |
| Income at or below: |
Not
Published |
| Other Income
Requirements: |
Add $25,000 for each extra person in household |
| Medical expenses
can be deducted from reported income: |
Not
Published |
| Social security requested on form: |
No |
| US citizenship/residency specified:
|
Not
Published |
|
|
APPLICATION |
|
| Attachments
Required: |
Financial
|
Physician
License #
Required: |
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Patient
|
| Quantity in
Shipment: |
Varies |
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
Not Published |
| Refill Policy: |
Not Published
|
| Other Information: |
|
|
|
Last Updated: 01/30/2024
www.RxAssist.org
|