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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
    Federal Poverty Level Calculator Federal Poverty Level Calculator
    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

     

     

     


    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.


    Document Patient Consent Form


    Document Spanish Patient Consent Form


    Document Prescriber Foundation Form



     

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