Perjeta Patient Assistance Programs

Perjeta: Apply for prescription assistance below

If you are eligible, the programs below can help you afford Perjeta. Review the information to see if you qualify. The applications are available in Adobe PDF format and should be mailed directly to the provider of the patient assistance program.

If you have any questions, please call the telephone number for the program (not PharmacyChecker.com) or go to the program website.

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Genentech Access to Care Foundation (Perjeta)

(Program 1 of 3 — Scroll down to see them all)

Provided by: Genentech, Inc.
Genentech Access Solutions 1 DNA Way, Mail Stop #858a South San Francisco, CA 94080-4990
TEL: 866-422-2377
ALT PHONE: 866-422-2377
FAX: 888-249-4919
Languages Spoken:
English, Spanish, Others By Translation Service
Program Website
Medications
  • Perjeta vial; single-use (pertuzumab vial; single-use)
Eligibility Requirements
  • Insurance Status Must have no prescription coverage or been denied coverage
  • Those with Part D Elibible? Determined case by case
  • Income Gross annual household income at or below $100,000
  • Diagnosis/Medical Criteria FDA-approved diagnosis
  • U.S. Residency Required? Must be treated by US licensed healthcare provider
Application
  • Obtaining Doctor/Doctor's office starts process by filling out enrollment/statement of medical necessity forms
  • Receiving Downloaded from website
  • Returning The completed application can be faxed or mailed back.
  • Doctor's Action Complete and sign statement of medical necessity
  • Applicant's Action Complete Patient Authorization and Notice of Information Form available on website, attach proof of income
  • Decision Communicated Not specified
  • Decision Timeframe Not specified
Medication
  • Amount/Supply Varies
  • Sent To Varies
  • Delivery Time Not specified
  • Refill Proces Not specified
  • Limit Not specified
  • Re-application New application yearly
Additional Information
None
Updated August 16, 2018

If you, your patient or loved one does not qualify for this program or other prescription savings programs, then please search for Perjeta prices here.

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Good Days Program

(Program 2 of 3 — Scroll down to see them all)

Provided by: Good Days from CDF
Attn: Enrollment 6900 Dallas Parkway Suite #200 Plano, TX 75024
TEL: 877-968-7233
FAX: 214-570-3621
Languages Spoken:
English
Program Website
Medications
  • Perjeta (pertuzumab)
Eligibility Requirements
  • Insurance Status Not specified
  • Those with Part D Elibible? Not specified
  • Income Not disclosed
  • Diagnosis/Medical Criteria Not specified
  • U.S. Residency Required? US residency requirements are not specified.
Application
  • Obtaining Call, download or apply online
  • Receiving Faxed, mailed or downloaded from website
  • Returning The completed application can be faxed, mailed or submitted online.
  • Doctor's Action Give prescription to patient
  • Applicant's Action Complete section, sign, attach required documents
  • Decision Communicated Patient and/or Doctor are notified
  • Decision Timeframe Varies
Medication
  • Amount/Supply Not specified
  • Sent To Not specified
  • Delivery Time Not specified
  • Refill Proces Not specified
  • Limit Not specified
  • Re-application Must re-enroll at end of calendar year
Additional Information
Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.
Updated August 2, 2018

If you, your patient or loved one does not qualify for this program or other prescription savings programs, then please search for Perjeta prices here.

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Patient Access Network Foundation (PAN)

(Program 3 of 3 — Scroll down to see them all)

Provided by: Patient Access Network Foundation
None
TEL: 866-316-7263
FAX: 866-316-7261
Languages Spoken:
English, Spanish, Others By Translation Service
Program Website
Medications
  • Perjeta (pertuzumab)
Eligibility Requirements
  • Insurance Status *See Additional Information section below
  • Those with Part D Elibible? Determined case by case
  • Income Between 400-500% of FPL
  • Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
  • U.S. Residency Required? Must reside and receive treatment in US
Application
  • Obtaining Call or complete online
  • Receiving Complete online or by phone
  • Returning Complete online or by phone
  • Doctor's Action Will be discussed with patient and Doctor after request is received
  • Applicant's Action Call for information or inform doctor that he/she is in need
  • Decision Communicated Patient and Doctor notified in writing
  • Decision Timeframe Within 48 hours
Medication
  • Amount/Supply Not applicable
  • Sent To Patient sent card to be used at pharmacy
  • Delivery Time Once approved; shipped same day
  • Refill Proces Patient presents voucher/card to pharmacy for each refill
  • Limit None
  • Re-application New application every 12 months
Additional Information
*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance. Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly. Note: All new enrollment is now done electronically or over the phone. Contact program for details.
Updated July 10, 2018

If you, your patient or loved one does not qualify for this program or other prescription savings programs, then please search for Perjeta prices here.

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