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

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

With your patient's consent, you can complete the form to enroll him or her in the CellCept® 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 1-833-CellCept (1-833-235-5237) 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 1-833-CellCept (1-833-235-5237) 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 1-833-CellCept (1-833-235-5237) 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. If you believe you have received this message in error, please call 1-833-CellCept (1-833-235-5237) 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 1-833-CellCept (1-833-235-5237) 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. Patients with government provided insurance programs such as Medicare or Medicaid are not eligible.

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 1-833-CellCept (1-833-235-5237) to speak with an agent.

Step 2 of 2: Patient information

An error has occurred. Please call 1-833-CellCept (1-833-235-5237) to speak with an agent.

*Required fields







Select
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • 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® 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 1-833-CellCept (1-833-235-5237) 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® 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 1-833-CellCept (1-833-235-5237) to speak with an agent.

Patient Consent

*I give my consent (or I have the patient’s consent) to enroll in the CellCept® 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 1-833-CellCept (1-833-235-5237) to speak with an agent.

*CellCept is used in combination with cyclosporine and corticosteroids.
By using the CellCept® Copay 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 CellCept® Co-pay Program is valid ONLY for patients with commercial (private or non-governmental) insurance who have a valid prescription for a Food and Drug Administration (FDA)-approved indication of a Genentech medication. Patients using Medicare, Medicaid, Medigap, Veteran’s Affairs (VA), Department of Defense (DoD), TRICARE or any other federal or state government program to pay for their medications are not eligible. The Program is not valid for medications that are eligible to be reimbursed in their entirety by private insurance plans or other programs.
Under the Program, the patient will pay a co-pay. After reaching the maximum Program benefit, the patient will be responsible for all Out-of-Pocket costs. This Program is not health insurance or a benefit plan. The Program does not obligate the use of any specific product or provider. Patients receiving assistance from charitable assistance programs (such as Genentech Patient Foundation) are not eligible. The Co-pay benefit cannot be combined with any other rebate, free trial, or similar offer for the medication. No party may seek reimbursement for all or any part of the benefit received through this Program.
The Program may be accepted by participating pharmacies, physician offices, or hospitals. Once enrolled, this Program will not honor claims with date of service or medication dispensing that precede Program enrollment by more than 120 days. Use of this Program must be consistent with all relevant health insurance requirements. Participating patients, pharmacies, physician offices, and hospitals are responsible for reporting the receipt of all Program benefits as required by any insurer or by law. Program benefits may not be sold, purchased, traded, or offered for sale, purchase, or trade.
The patient or their guardian must be 18 years or older for the patient to be eligible. This Program is only valid in the United States and U.S. Territories. This Program is void where prohibited by law and shall follow state restrictions in relation to AB-rated generic equivalents (e.g. MA, CA) where applicable. Program eligibility is contingent upon the patient’s ability to meet and maintain all requirements set forth by the Program. Genentech 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® 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® Copay 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 CellCept® Co-pay Program is valid ONLY for patients with commercial (private or non-governmental) insurance who have a valid prescription for a Food and Drug Administration (FDA)-approved indication of a Genentech medication. Patients using Medicare, Medicaid, Medigap, Veteran’s Affairs (VA), Department of Defense (DoD), TRICARE or any other federal or state government program to pay for their medications are not eligible. The Program is not valid for medications that are eligible to be reimbursed in their entirety by private insurance plans or other programs.
Under the Program, the patient will pay a co-pay. After reaching the maximum Program benefit, the patient will be responsible for all Out-of-Pocket costs. This Program is not health insurance or a benefit plan. The Program does not obligate the use of any specific product or provider. Patients receiving assistance from charitable assistance programs (such as Genentech Patient Foundation) are not eligible. The Co-pay benefit cannot be combined with any other rebate, free trial, or similar offer for the medication. No party may seek reimbursement for all or any part of the benefit received through this Program.
The Program may be accepted by participating pharmacies, physician offices, or hospitals. Once enrolled, this Program will not honor claims with date of service or medication dispensing that precede Program enrollment by more than 120 days. Use of this Program must be consistent with all relevant health insurance requirements. Participating patients, pharmacies, physician offices, and hospitals are responsible for reporting the receipt of all Program benefits as required by any insurer or by law. Program benefits may not be sold, purchased, traded, or offered for sale, purchase, or trade.
The patient or their guardian must be 18 years or older for the patient to be eligible. This Program is only valid in the United States and U.S. Territories. This Program is void where prohibited by law and shall follow state restrictions in relation to AB-rated generic equivalents (e.g. MA, CA) where applicable. Program eligibility is contingent upon the patient’s ability to meet and maintain all requirements set forth by the Program. Genentech reserves the right to rescind, revoke, or amend the Program without notice at any time.