Additional Options to Request Product Shipment via Fax
Use the Upfront Shipment Request Form to request medicine to be delivered to the patient's home or the health care provider's office through the Foundation's specialty pharmacy partner. Use this form to request shipment for the following Genentech medicines:
Genentech Medicines Eligible for Upfront Shipment
ACTEMRA® (tocilizumab)
Avastin® (bevacizumab)
ENSPRYNG™ (satralizumab-mwge)
GAZYVA® (obinutuzumab)
Herceptin® (trastuzumab)
Herceptin HYLECTA™ (trastuzumab and hyaluronidase-oysk)
KADCYLA® (ado-trastuzumab emtansine)
LUCENTIS® (ranibizumab injection)
OCREVUS® (ocrelizumab)
PEGASYS® (peginterferon alfa-2a)
PERJETA® (pertuzumab)
PHESGOTM (pertuzumab, trastuzumab, and hyaluronidase-zzxf)
POLIVY™ (polatuzumab vedotin-piiq)
Rituxan® (rituximab)
RITUXAN HYCELA® (rituximab/hyaluronidase human)
ROZLYTREKTM (entrectinib)
TECENTRIQ® (atezolizumab)
XELODA® (capecitabine)
XOLAIR® (omalizumab) for subcutaneous use
Use the Product Replacement Form to request replacement medicine when an enrolled patient was treated with medicine from the health care provider's inventory. Use this form to request replacement for the following Genentech medicines:
Genentech Medicines Eligible for Product Replacement
ACTEMRA® (tocilizumab)
ACTIVASE® (alteplase)
Avastin® (bevacizumab)
Cathflo® Activase (alteplase)
GAZYVA® (obinutuzumab)
Herceptin® (trastuzumab)
Herceptin HYLECTA™
(trastuzumab and hyaluronidase-oysk)
KADCYLA® (ado-trastuzumab emtansine)
LUCENTIS® (ranibizumab injection)
OCREVUS® (ocrelizumab)
PEGASYS® (peginterferon alfa-2a)
PERJETA® (pertuzumab)
PHESGOTM (pertuzumab, trastuzumab, and hyaluronidase-zzxf)
POLIVY™ (polatuzumab vedotin-piiq)
Rituxan® (rituximab)
RITUXAN HYCELA® (rituximab/hyaluronidase human)
TECENTRIQ® (atezolizumab)
TNKase® (tenecteplase)
XOLAIR® (omalizumab) for subcutaneous use
Shipping/Logistics
Prescriptions will be distributed through our specialty pharmacy partner or through a product replacement model. For Genentech medicines that are administered by a health care provider, we are asking providers to select one distribution option. If you have questions about shipment options, a Genentech Patient Foundation Specialist can help.
Request medicines on the Prescriber Foundation form. This must be completed by a health care provider. Download the form by clicking here.
Patient Consent Form
The Patient Consent form must also be submitted to apply for help. This must be completed by a patient or their legally authorized person. Download the Patient Consent form by clicking here.