Alecensa Access Solutions Bridge Program

Funded

About

The Alecensa Access Solutions Bridge Program offers substantial support to patients through the provision of free Alecensa medication while waiting for insurance coverage determination. Intended for those prescribed Alecensa for FDA-approved uses, this program ensures patients with private or commercial insurance can receive necessary treatments promptly.

Insurance requirements: Commercially insured, Underinsured

Enrollment Forms

Enrollment Form

Program Requirements

•Valid only for residents in the US and Puerto Rico

•Enrollment Required: Yes

•Coverage Required: No

•Needs Based: No

•Activation Required: No

Program Details

•Eligible patients taking Alecensa may receive free medicine while awaiting an insurance coverage determination

•BOTH the Prescriber Service Form and the Patient Consent Form must be received before ALECENSA Access Solutions can begin helping the patient

•HCP must fax the completed Prescriber Service Form to Actemra Access Solutions at 8882494919; call 8882494918 for assistance

•Patient must submit the completed Patient Consent Form to Alecensa Access Solutions by texting a photo of the page to 6508771111 or faxing form to 8664807762 (https://www.genentechaccess.com/content/dam/gene/accesssolutions/pdfs/patientconsentform/GenentechAccessSolutionsPatientConsent_Form.pdf)

•Patient can also complete the consent form online at https://www.genentechaccess.com/patient/patientconsent.html

•For assistance completing patient consent form, call Genentech Access Solutions at 8664222377 6 a.m.–5 p.m. PT, Monday through Friday

•For assistance, call 8774363683 6 a.m.–5 p.m. PT, Monday through Friday

Enrollment Forms

Enrollment Form

Other Programs

Assistance Fund: Non-Small Cell Lung Cancer (NSCLC)

Commercially Insured

Medicare / Medicaid

Underinsured

Uninsured

Assistance Fund: Non-Small Cell Lung Cancer: Waitlist

Commercially Insured

Medicare / Medicaid

Underinsured

Uninsured

Other Tools for Alecensa

Get prior authorization forms

Get patient education materials