ALECENSA

Indicated For

Non-small cell lung cancer (NSCLC), anaplastic lymphoma kinase-positive (ALK-positive)

About This Medication

# Genentech Oncology Co-pay Assistance Program Patient Guide: How to Get ALECENSA at Low or No Cost ## About This Program If you've been prescribed ALECENSA (alectinib) to treat ALK-positive non-small cell lung cancer (NSCLC), you may be eligible for the **Genentech Oncology Co-pay Assistance Program**. This program helps eligible patients reduce or eliminate their out-of-pocket costs for ALECENSA, including co-pays, co-insurance, and deductibles. ## About ALECENSA ALECSA is a targeted cancer therapy known as an ALK inhibitor. It works by blocking the activity of abnormal ALK proteins that can drive the growth of certain lung cancer cells. ALECENSA is specifically designed for patients whose tumors have the ALK mutation. As a specialized cancer medication, ALECENSA can be expensive, and this assistance program exists to help ensure cost doesn't prevent you from accessing your treatment. ## Who Can Qualify? You may be eligible for this program if you meet ALL of the following criteria: - **You have a valid prescription** for ALECENSA from your doctor - **You have commercial insurance** (private health insurance plans) - **Your household income** falls within the program's limits (see income table below) - **You are a U.S. resident** - **Your insurance claim is NOT reimbursed** through Medicare, Medicaid, or other federal/state government programs ### Important Insurance Note This program is **NOT available** if your prescription is paid for through: - Medicare (including Part D) - Medicaid - Veterans Administration (VA) - State pharmaceutical assistance programs - Other government-funded insurance programs If you're on government insurance, ask your healthcare team about alternative assistance options. ## Income Eligibility Guidelines Your household size and total annual income determine eligibility. The program uses flexible income thresholds that vary based on circumstances. Here's a general framework: | Household Size | Approximate Maximum Income Range | |---|---| | 1 person | Varies (contact program for exact amount) | | 2 people | Varies (contact program for exact amount) | | 3 people | Varies (contact program for exact amount) | | 4 people | Varies (contact program for exact amount) | | 5+ people | Varies (contact program for exact amount) | **Note:** Income limits are flexible and vary by individual circumstances. Even if your income seems slightly above these estimates, you should still apply. Call the program at **(855) 692-6729** to discuss your specific situation. The program representatives can tell you the exact current income limits and help determine your eligibility. ## What You'll Need to Apply Before you begin, gather these documents: 1. **Prescriber Service Form** - Your doctor's office will complete this form with your prescription details and medical information 2. **Patient Consent Form** - You'll sign this to authorize the program to assist with your prescription 3. **Proof of income** (examples: recent tax return, W-2, pay stub, or other income documentation) 4. **Insurance card** (front and back copies) 5. **Photo ID** (copy of driver's license or state ID) 6. **List of current medications** (optional but helpful) ## Step-by-Step Application Instructions ### Step 1: Confirm Your Eligibility Before investing time in the application, confirm you meet the basic requirements: - Do you have commercial insurance (NOT Medicare, Medicaid, or VA)? - Is your household income within program guidelines? - Does your insurance NOT cover your prescription through a government program? If you answer "yes" to all three, move to Step 2. ### Step 2: Contact the Program Call **Genentech Oncology Co-pay Assistance Program at (855) 692-6729** - Have your insurance card ready - Ask them to confirm your eligibility - Request the application materials - Ask about the current exact income limits for your household size - Get clarification on any requirements ### Step 3: Get Your Doctor's Paperwork Contact your oncology clinic or prescribing physician's office: - Ask them to complete the **Prescriber Service Form** - This typically takes 3-5 business days - Provide them with the program's contact information if needed - They may be able to submit documents directly to the program ### Step 4: Complete Your Application You can apply using **multiple methods**: **Option A: Online Application** - Visit https://www.copayassistancenow.com - Complete the online form - Upload required documents - Receive confirmation email **Option B: Phone Application** - Call (855) 692-6729 - Speak with a representative - Provide information verbally - They'll confirm receipt and next steps **Option C: Mail/Paper Application** - Request a paper application - Complete forms by hand - Attach supporting documents - Mail to address provided by program ### Step 5: Submit Required Documents Make sure to include: - Completed Patient Consent Form (signed) - Completed Prescriber Service Form (from your doctor) - Proof of income - Insurance card copies - Photo ID copy ### Step 6: Wait for Approval The program typically processes applications within **4-8 weeks**. You'll receive: - Approval letter (or denial with explanation) - Instructions for receiving your medication - Details about your co-pay assistance amount - Authorization numbers if applicable ## Your Medication Will Arrive Once approved, your ALECENSA will be dispensed through a **specialty pharmacy**. This is a pharmacy specialized in handling cancer medications and complex therapies. - You'll receive instructions on how to pick up or receive delivery of your medication - Specialty pharmacies often provide additional support services - Your co-pay assistance will be applied automatically - Ask the specialty pharmacy about delivery options (mail delivery, pickup, etc.) ## Reauthorization This assistance is **not permanent**. You'll need to **reauthorize annually** to continue receiving help. The program will contact you when it's time to renew. - Plan ahead: apply for renewal 2-3 months before your current authorization expires - You may need to update income information or insurance details - The reauthorization process is typically simpler than the initial application ## What If Your Application Is Denied? If you're denied assistance, you have several options: 1. **Appeal the decision** - Ask why you were denied and if you can provide additional information 2. **Explore alternatives** - See section below on other resources 3. **Contact your doctor's office** - They may have other patient assistance options or clinical trial information 4. **Reach out to patient advocacy organizations** - Organizations like LUNGevity or the Lung Cancer Alliance may offer additional resources ## Alternative Resources If You Don't Qualify If you're ineligible for this program, other options may be available: - **NeedyMeds.org** - Database of patient assistance programs across all manufacturers - **Patient advocacy organizations** - Groups like LUNGevity Foundation, American Cancer Society - **Your doctor's connections** - Oncology practices often have relationships with programs that can help - **Hospital financial counselors** - Ask for a referral to your hospital's financial assistance office - **State pharmaceutical assistance programs** - Many states offer help for uninsured or underinsured residents - **Clinical trials** - Ask your doctor if you might qualify for a clinical trial (medication provided at no cost) ## Questions? Contact Information **Genentech Oncology Co-pay Assistance Program** - **Phone:** (855) 692-6729 - **Website:** https://www.copayassistancenow.com - **Hours:** [Contact the program for hours of operation] Program representatives can answer questions about: - Eligibility based on your specific situation - Income limits for your household - Application status - Document requirements - Medication delivery - Reauthorization procedures ## Important Legal Information This guide provides general information about the Genentech Oncology Co-pay Assistance Program. Program eligibility, requirements, and benefits can change at any time. Always verify current requirements directly with the program at (855) 692-6729 or https://www.copayassistancenow.com. This program is provided by Genentech, Inc. (the manufacturer of ALECENSA). Participation is voluntary, and the program is subject to all applicable laws and regulations. For medical questions about ALECENSA itself, speak with your oncologist or healthcare provider. --- **Last Updated:** 2024 **This guide is for informational purposes only and should not replace official program information.**

Program information last verified: March 25, 2026