Enroll your patients in the CellCept® $15 Co-pay Card program

Some patients may have trouble paying for their medicine. Genentech has an assistance program to help these patients get the medicine they need: the CellCept® $15 Co-pay Card program.

If your patient has commercial insurance, he or she may qualify for the CellCept® $15 Co-pay Card, regardless of income. It is for people who have insurance that is not offered through the government. Government-provided insurance includes programs such as Medicare or Medicaid.

With your patient's consent, you can complete the form to enroll him or her in the CellCept® $15 Co-pay Card program. If he or she qualifies, you can print a card today that the patient can use when filling the prescription.

Step 1 of 2: Find out if your patient is eligible

1. Are you 18 years of age or older?

You must be 18 years or older to complete this form. Please have a parent or a legally authorized person who is at least 18 years of age complete the enrollment.

If you believe you have received this message in error, please call 1-855-SAV-CELL (1-855-728-2355) to speak with an agent.

2. For what has brand-name CellCept been prescribed for?

The patient must be prescribed brand-name CellCept for an FDA-approved indication to use the co-pay program.

If you believe you have received this message in error, please call 1-855-SAV-CELL (1-855-728-2355) to speak with an agent.

3. Does the patient have commercial insurance? (Like the type you get through an employer or directly from an insurance company. Healthcare exchange plans that are offered through the Affordable Care Act are considered commercial insurance.)

The patient is not eligible for the program. It is intended for patients with commercial insurance. Click here to find out about additional assistance that the patient may be eligible to receive.

If you believe you have received this message in error, please call 1-855-SAV-CELL (1-855-728-2355) to speak with an agent.

4. What is the patient’s state (or territory) of residence?

Select
  • Not a United States resident
  • Alabama
  • Alaska
  • American Samoa
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Guam
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Northern Mariana Islands
  • Ohio
  • Oklahoma
  • Oregon
  • Pennsylvania
  • Puerto Rico
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virgin Islands
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming

The patient is not eligible for the program. The program is only valid for residents of the United States and Puerto Rico. The program is not valid for residents of Massachusetts. Click here to find out about additional assistance that the patient may be eligible to receive.

If you believe you have received this message in error, please call 1-855-SAV-CELL (1-855-728-2355) to speak with an agent.

5. Is the patient receiving free drug assistance through the Genentech® Access to Care Foundation (GATCF) or any other charitable organization?

The patient is not eligible for the program.

If you believe you have received this message in error, please call 1-855-SAV-CELL (1-855-728-2355) to speak with an agent.

6. Is the patient a government beneficiary and/or enrolled in any state- or federally funded healthcare program, including but not limited to all Medicare, Medicaid, Medigap, VA, DoD, or TRICARE? We may contact the patient by phone or mail periodically in order to verify that the patient's eligibility for the program has not changed.

The patient is not eligible for the program. The card cannot be used with Medicare, Medicaid, or any other federal or state program. Click here to find out about additional assistance that the patient may be eligible to receive.

If you believe you have received this message in error, please call 1-855-SAV-CELL (1-855-728-2355) to speak with an agent.

Step 2 of 2: Patient information

An error has occurred. Please call 1-855-SAV-CELL (1-855-728-2355) to speak with an agent.

*Required fields







Select
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Pennsylvania
  • Puerto Rico
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming


How did you hear about the program?

Select
  • Healthcare Provider
  • Transplant Coordinator/Team
  • CellCept® Co-pay Card Brochure
  • Online Search
  • CellCept.com
  • Email
  • Pharmacy
  • In-office Poster
  • Online Ads
  • Other

Are you the patient?*

Enroller information







Select
  • Alabama
  • Alaska
  • American Samoa
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Guam
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Northern Mariana Islands
  • Ohio
  • Oklahoma
  • Oregon
  • Pennsylvania
  • Puerto Rico
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virgin Islands
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming



Terms and Conditions

*The patient information disclosed during this enrollment, including name, email address, mailing address, and phone number, will be shared with Genentech, the sponsor of the card. In addition, information shared by the patient’s pharmacy/physician, such as the date the patient filled the prescription, the date the medication was administered by the patient’s physician (if applicable), and the amount that the patient will be reimbursed by Genentech, will be shared with Genentech, the sponsor of this card. The patient agrees to be contacted by phone, mail, or email with the information and/or materials about the patient’s Genentech CellCept® $15 Co-pay Card. For more information, please see the Genentech Privacy Policy at www.gene.com.

You must give your consent (or the patient must give his or her consent) to enroll in the program.

If you believe you have received this message in error, please call 1-855-SAV-CELL (1-855-728-2355) to speak with an agent.

*I have read and agreed (or the patient has read and agreed) to the terms and conditions of the CellCept® $15 Co-pay Card program.

You must read and agree (or the patient must read and agree) to the terms and conditions in order to enroll in the program.

If you believe you have received this message in error, please call 1-855-SAV-CELL (1-855-728-2355) to speak with an agent.

Patient Consent

*I give my consent (or I have the patient’s consent) to enroll in the CellCept® $15 Co-pay Card program.

You must give your consent (or the patient must give his or her consent) to enroll in the program.

If you believe you have received this message in error, please call 1-855-SAV-CELL (1-855-728-2355) to speak with an agent.

*CellCept is used in combination with cyclosporine and corticosteroids.
By using the CellCept® $15 Co-pay Card program, the patient acknowledges and confirms that at the time of usage, (s)he is currently eligible and meets the criteria set forth in the terms and conditions described.
This Co-pay Card is valid ONLY for patients with commercial (private or non-governmental) insurance who are taking the medication for an FDA-approved indication. Patients using Medicare, Medicaid, or any other government-funded program to pay for their medications are not eligible. Patients who start utilizing their government coverage during their enrollment period will no longer be eligible for the program.
This Co-pay Card program is not health insurance or a benefit plan. Distribution or use of the Co-pay Card does not obligate use or continuing use of any specific product or provider. Patient or guardian is responsible for reporting the receipt of all Co-pay Card program benefits or reimbursement received, to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the Co-pay Card program, as may be required.
The Co-pay Card is not valid for medications the patient receives for free or that are eligible to be reimbursed by private insurance plans or other healthcare or pharmaceutical assistance programs (such as GATCF or any other charitable organization) that reimburse the patient in part or for the entire cost of his/her Genentech medication. Patient, guardian, pharmacist, prescriber, and any other person using the Co-pay Card agree not to seek reimbursement for all or any part of the benefit received by the recipient through the offer.
The Co-pay Card will be accepted by participating pharmacies, physician offices, or hospitals. To qualify for the benefits of this Co-pay Card program, the patient may be required to pay out-of-pocket expenses for each treatment. Once enrolled, this Co-pay Card program will not honor claims with date of service or medication dispensing that precede program enrollment by more than 120 days. This Co-pay Card is only available with a valid prescription and cannot be combined with any other rebate/coupon, free trial, or similar offer for the specified prescription. Use of this Co-pay Card must be consistent with all relevant health insurance requirements and payer agreements. Participating patients, pharmacies, physician offices, and hospitals are obligated to inform third-party payers about the use of the Co-pay Card as provided for under the applicable insurance or as otherwise required by contract or law. The Co-pay Card may not be sold, purchased, traded, or offered for sale, purchase, or trade. The Co-pay Card is limited to 1 per person during this offering period and is not transferable. This program expires within 12 months from enrollment. This program is not valid where prohibited by law. For Massachusetts’ residents, the Co-pay Card is not valid for any prescription drug that has an AB-rated generic equivalent as determined by the United States Food and Drug Administration. For Massachusetts’ residents, this program shall expire on or before July 1, 2019.

The patient or his/her guardian must be 18 years or older to receive Co-pay Card program assistance. This Co-pay Card program is: (1) void if the card is reproduced; (2) void where prohibited by law; (3) only valid in the United States and Puerto Rico; and (4) only valid for Genentech products. Healthcare providers may not advertise or otherwise use the program as a means of promoting their services or Genentech’s products to patients. Genentech, Inc. reserves the right to rescind, revoke, or amend the program without notice at any time.

Success!

Success!

The patient is signed up for the CellCept® $15 Co-pay Card program

A printed CellCept® Co-pay Card will arrive by mail in 5 to 7 business days. But the patient can start using the Co-pay Card benefits today. Simply click the button below and print out a temporary version of the card.

How to use the card

The patient should present the card to the pharmacist:

  • If the patient’s pharmacy can store the co-pay card information, he or she may not need to present the card each month
  • If the patient uses a specialty or mail order pharmacy, he or she should provide the co-pay card details over the phone

Learn more about patient financial assistance.

*CellCept is used in combination with cyclosporine and corticosteroids.

By using the CellCept® $15 Co-pay Card program, the patient acknowledges and confirms that at the time of usage, (s)he is currently eligible and meets the criteria set forth in the terms and conditions described.

This Co-pay Card is valid ONLY for patients with commercial (private or non-governmental) insurance. Patients using Medicare, Medicaid or any other government funded program to pay for their medications are not eligible. Patients who start utilizing their Government coverage during their enrollment period will no longer be eligible for the program.

This Co-pay Card program is not health insurance or a benefit plan. Distribution or use of the Co-pay Card does not obligate use or continuing use of any specific product or provider. Patient or guardian is responsible for reporting the receipt of all Co-pay Card program benefits or reimbursement received, to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the Co-pay Card program, as may be required.

The Co-pay Card is not valid for medications the patient receives for free or that are eligible to be reimbursed by private insurance plans or other healthcare or pharmaceutical assistance programs (such as: GATCF or any other charitable organization) that reimburse the patient in part or for the entire cost of his/her medication. Patient, guardian, pharmacist, prescriber and any other person using the Co-pay Card agree not to seek reimbursement for all or any part of the benefit received by the recipient through the offer.

The Co-pay Card will be accepted by participating pharmacies, physician offices or hospitals. To qualify for the benefits of this Co-pay Card program, the patient may be required to pay out-of-pocket expenses for each treatment. Once enrolled, this Co-pay Card program will not honor claims with date of service or medication dispensing that precede program enrollment by more than 120 days. This Co-pay Card is only available with a valid prescription and cannot be combined with any other rebate/coupon, free trial, or similar offer for the specified prescription. Use of this Co-pay Card must be consistent with all relevant health insurance requirements and payer agreements. Participating patients, pharmacies, physician offices and hospitals are obligated to inform third-party payers about the use of the Co-pay Card as provided for under the applicable insurance or as otherwise required by contract or law. The Co-pay Card may not be sold, purchased, traded or offered for sale, purchase or trade. The Co-pay Card is limited to 1 per person during this offering period and is not transferable.  This program expires within 12 months from enrollment.  This program is not valid where prohibited by law. For Massachusetts’ residents, the Co-pay Card is not valid for any prescription drug that has an AB rated generic equivalent as determined by the United States Food and Drug Administration. For Massachusetts’ residents, this program shall expire on or before July 1, 2019.

The patient or their guardian must be 18 years or older to receive Co-pay Card program assistance. This Co-pay Card program is: (1) Void if the card is reproduced; (2) Void where prohibited by law; (3) only valid in the United States and Puerto Rico; and (4) only valid for Genentech products. Healthcare providers may not advertise or otherwise use the program as a means of promoting their services or Genentech’s products to patients. Genentech, Inc. reserves the right to rescind, revoke, or amend the program without notice at any time.