Activase

Indicated For

Acute Ischemic Stroke, Myocardial Infarction, Pulmonary Embolism

About This Medication

# Genentech Patient Foundation Patient Guide: How to Get Activase (Alteplase) at Low or No Cost ## About This Program The **Genentech Patient Foundation** is a patient assistance program designed to help individuals access Genentech medicines, including Activase (alteplase), when cost is a barrier to treatment. This program provides free or reduced-cost medication to eligible patients regardless of insurance status. Activase is a thrombolytic (clot-busting) medication used to treat acute myocardial infarction (heart attack), acute ischemic stroke, and pulmonary embolism. If you've been prescribed Activase and are concerned about affording it, this guide will help you understand your options. ## Who Qualifies for Assistance You may qualify for the Genentech Patient Foundation if you meet one of these criteria: - **Uninsured**: You have no health insurance coverage - **Underinsured**: You have insurance but it doesn't cover Activase - **Financial Hardship**: You have insurance but cannot afford the out-of-pocket costs (your out-of-pocket maximum exceeds 7.5% of your yearly household income) - **Income-Based Eligibility**: Your household income falls below 200-400% of the Federal Poverty Level (FPL) The program serves patients living in the United States who are being treated by a US-licensed physician. **The program does not require or collect citizenship or immigration information.** ## Income Eligibility Breakdown While specific income thresholds vary based on household size and individual circumstances, the program generally considers households with income below 200-400% of the Federal Poverty Level. Use the Confirm Financial Eligibility form available on the Genentech website, or call a Foundation Specialist at **(888) 941-3331** to determine if your specific situation qualifies. | Eligibility Category | Requirements | |---|---| | Uninsured | No active health insurance | | Insured with Coverage Gap | Insurance doesn't cover Activase | | Insured with High Out-of-Pocket Costs | Out-of-pocket maximum exceeds 7.5% of yearly income | | Income-Based | Household income below 200-400% FPL | ## Insurance Requirements The Genentech Patient Foundation can help you regardless of your insurance status: - **If you're uninsured**: You may qualify based on financial need - **If you have Medicare or Medicaid**: You may still qualify for assistance with cost-sharing or copayments - **If you have private insurance**: You may qualify if your plan doesn't cover Activase or if your out-of-pocket costs create financial hardship - **If you're underinsured**: You may qualify if your coverage is insufficient You can apply for assistance while appealing an insurance denial—proof of appeal is not required. ## Step-by-Step Application Process ### Step 1: Complete the Patient Consent Form Start by filling out the **Patient Consent Form**, available in English and Spanish. You can complete this form online or print it and fill it out by hand. This form collects your personal information, household size, income details, and insurance status. **How to submit the Patient Consent Form:** - **Online**: Use eSubmit on the Genentech website for fastest processing - **Text**: Take a photo of the signed form and text it to **(650) 877-1111** - **Fax**: Send to **(833) 999-4363** - **Mail**: Send to the address provided on the form ### Step 2: Notify Your Doctor Once you've completed the Patient Consent Form, inform your doctor's office that you're applying for assistance from the Genentech Patient Foundation. Your doctor will need to complete their portion of the application. ### Step 3: Your Doctor Completes the Prescriber Foundation Form Your healthcare provider must complete and sign the **Prescriber Foundation Form** (Page 2). This form verifies your prescription and medical need for Activase. Your doctor's office can submit this form directly to Genentech. **How your doctor submits the Prescriber Form:** - **Online**: Through My Patient Solutions (if your practice has a registered account) - **Fax**: To **(833) 999-4363** - **Mail**: To the address provided on the form ### Step 4: Submit Both Forms Together **Both the Patient Consent Form and the Prescriber Foundation Form must be received for processing to begin.** Submitting them together ensures faster processing. Do not submit additional documents beyond what's requested, as this may cause delays. ### Step 5: Await Eligibility Determination Once Genentech receives both completed forms, they will process your application and contact both you and your doctor to discuss the outcome and next steps. ## Timeline and Delivery **Processing Time**: Your application will be processed within **5 business days** of receiving both required forms. In some cases, processing may take up to 2-6 weeks depending on the complexity of your situation. **Delivery Method**: Once approved, Activase will be shipped to your physician's office or directly to your home, depending on what's arranged during your eligibility discussion. **What to Expect**: After an eligibility determination is made, both you and your prescriber will be contacted to discuss your application outcome and any next steps, including how your medication will be delivered. ## Required Documentation To complete your application, have the following information ready: - **Proof of income** (recent pay stubs, tax returns, or benefit statements) - **Proof of residency** (utility bill or lease agreement) - **Valid prescription** for Activase from your US-licensed physician - **Insurance information** (if applicable—policy number, coverage details) - **Household size and composition** Only the information requested on the enrollment forms is required. Providing unrequested documents may delay processing. ## What If Your Application Is Denied? If you don't qualify for the Genentech Patient Foundation, other assistance options may be available: - **Genentech Access Solutions**: Can help you understand your insurance coverage and explore other assistance programs - **Insurance Appeals**: You can file an appeal with your insurance company while applying for foundation assistance - **Other Patient Assistance Programs**: Other organizations may offer financial support for Activase Contact a Foundation Specialist at **(888) 941-3331** to discuss alternative options if your application is denied. ## Reauthorization and Refills Your assistance through the Genentech Patient Foundation may require periodic reauthorization. Your doctor's office and the foundation will contact you about renewal requirements. Continue communicating with your healthcare provider about your ongoing medication needs. ## Get Help **Call a Foundation Specialist**: **(888) 941-3331** - **Hours**: Monday–Friday, 6 a.m.–5 p.m. PT - Foundation Specialists can answer questions, help determine eligibility, and guide you through the application process - Support is available in many different languages **Online Resources**: Visit GenentechPatientFoundation.com or Gene.com/patients for forms, FAQs, and additional information. ## Important Disclaimer This guide provides general information about the Genentech Patient Foundation. Program eligibility, requirements, and benefits may change. For the most current and accurate information, contact the Genentech Patient Foundation directly or visit their official website. This program is intended for patients living in the United States being treated by US-licensed physicians. Always consult with your healthcare provider about your treatment options and financial assistance eligibility.

Program information last verified: March 30, 2026