Referrals to the Genentech® Access to Care Foundation (GATCF)
GATCF provides free medicine to eligible patients who are uninsured,
rendered uninsured by payer denial or underinsured. To qualify,
patients must meet financial criteria.
Is My Patient Eligible?
Does your patient have health insurance?
Is your patient’s annual household adjusted gross income (AGI) less than $100,000?
Is your patient’s annual household adjusted gross income (AGI) less than $150,000?
Does your patient spend 5% or more of his or her annual household AGI on the out-of-pocket costs for his or her Genentech medicine?
Your Patient Appears to Be Eligible for GATCF
To get started with GATCF, complete and submit the SMN and PAN to Avastin Access Solutions. Patients must complete Sections 5 and 6 of the PAN to apply for GATCF.
Your Patient Does Not Appear to Be Eligible for GATCF, but Other Options May Be Available
Several options are available to help eligible patients with the out-of-pocket costs of their Genentech medicines.
Call Avastin Access Solutions at (888) 249-4918 or use our Patient Assistance Tool to find out which option may be right for your patient.
To be eligible for free Genentech medicine from GATCF, insured
patients must have exhausted all other forms of patient assistance
(including Genentech brand-specific co-pay cards and support from
independent co-pay assistance foundations) and meet financial
criteria. Uninsured patients must meet different financial criteria.
Download this flash card to view a summary of GATCF eligibility and
Only the information requested on these forms is required. Providing additional documents or information will delay processing.
Once we receive your patient’s information, Avastin Access Solutions
will contact the patient with further instructions. This may include
verifying financial eligibility.
PAN=Patient Authorization and Notice of Request
for Transmission of Health Information to Genentech Access Solutions
and Genentech® Access to Care Foundation.
SMN=Statement of Medical Necessity.
Important Safety Information & Indication
Avastin, in combination with intravenous 5‑fluorouracil-based chemotherapy, is indicated for the first‑ or second‑line treatment of patients with metastatic colorectal cancer.
Avastin, in combination with fluoropyrimidine-irinotecan- or fluoropyrimidine-oxaliplatin-based chemotherapy, is indicated for the second‑line treatment of patients with metastatic colorectal cancer who have progressed on a first-line Avastin-containing regimen.
Limitation of Use: Avastin is not indicated for adjuvant treatment of colon cancer.
Avastin, in combination with carboplatin and paclitaxel, is indicated for the first‑line treatment of patients with unresectable, locally advanced, recurrent or metastatic non–squamous non–small cell lung cancer.
Avastin, in combination with interferon alfa, is indicated for the treatment of metastatic renal cell carcinoma.
Avastin is indicated for the treatment of recurrent glioblastoma in adults.
Avastin, in combination with paclitaxel and cisplatin or paclitaxel and topotecan, is indicated for the treatment of patients with persistent, recurrent, or metastatic cervical cancer.
Avastin, in combination with carboplatin and paclitaxel, followed by Avastin as a single agent, is indicated for the treatment of patients with stage III or IV epithelial ovarian, fallopian tube, or primary peritoneal cancer following initial surgical resection.
Avastin, in combination with paclitaxel, pegylated liposomal doxorubicin, or topotecan, is indicated for the treatment of patients with platinum-resistant recurrent epithelial ovarian, fallopian tube or primary peritoneal cancer who received no more than 2 prior chemotherapy regimens.
Avastin, in combination with carboplatin and paclitaxel, or with carboplatin and gemcitabine, followed by Avastin as a single agent, is indicated for the treatment of patients with platinum-sensitive recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer.
Important Safety Information
- Gastrointestinal (GI) perforation
- Serious and sometimes fatal GI perforation occurs at a higher incidence in Avastin-treated patients compared to patients treated with chemotherapy
- The incidence of GI perforation ranged from 0.3% to 3% across clinical studies
- Discontinue Avastin in patients with GI perforation
- Surgery and wound healing complications
- The incidence of wound healing and surgical complications, including serious and fatal complications, is increased in Avastin-treated patients
- Withhold Avastin for at least 28 days prior to elective surgery. Do not administer Avastin for at least 28 days after surgery and until the wound is fully healed
- Discontinue in patients with wound healing complications requiring medical intervention
- Severe or fatal hemorrhage, including hemoptysis, GI bleeding, hematemesis, central nervous system hemorrhage, epistaxis, and vaginal bleeding, occurred up to 5-fold more frequently in patients receiving Avastin. In clinical studies, the incidence of grade ≥3 hemorrhagic events among patients receiving Avastin ranged from 0.4% to 7%
- Do not administer Avastin to patients with serious hemorrhage or a recent history of hemoptysis (≥1/2 tsp of red blood)
- Discontinue Avastin in patients who develop grade 3-4 hemorrhage
Additional serious adverse events
- Additional serious and sometimes fatal adverse events with increased incidence in the Avastin-treated arm vs chemotherapy arm included:
- Non-GI fistulae (<1% to 1.8%, highest in patients with cervical cancer)
- Arterial thromboembolic events (grade ≥3, 5%, highest in patients with GBM)
- Renal injury and proteinuria
- Grade 3–4 proteinuria ranged from 0.7% to 7% in clinical studies
- Nephrotic syndrome (<1%)
- Additional serious adverse events with increased incidence in the Avastin-treated arm vs chemotherapy arm included:
- Venous thromboembolism (grade ≥3, 11% seen in GOG-0240)
- Hypertension (grade 3–4, 5%–18%)
- Posterior reversible encephalopathy syndrome (PRES) (<0.5%)
- Congestive heart failure (CHF) (1%)
- Infusion reactions with the first dose of Avastin occurred in <3% of patients, and severe reactions occurred in 0.2% of patients
- Avoid use in patients with ovarian cancer who have evidence of recto-sigmoid involvement by pelvic examination or bowel involvement on CT scan or clinical symptoms of bowel obstruction
- Inform females of reproductive potential of the risk of ovarian failure prior to initiating treatment with Avastin
- Based on the mechanism of action and animal studies, Avastin may cause fetal harm
- Advise female patients that Avastin may cause fetal harm, and to inform their healthcare provider of a known or suspected pregnancy
- Advise females of reproductive potential to use effective contraception during treatment with Avastin and for 6 months after the last dose of Avastin
- Advise nursing women that breastfeeding is not recommended during treatment with Avastin and for 6 months following their last dose of treatment
- Avastin may impair fertility
Most common adverse events
- Across studies, the most common adverse reactions observed in Avastin patients at a rate >10% were:
- Taste alteration
- Dry skin
- Rectal hemorrhage
- Lacrimation disorder
- Back pain
- Exfoliative dermatitis
Across all studies, Avastin was discontinued in 8% to 22% of patients because of adverse reactions
You may report side effects to the FDA at (800) FDA-1088 or www.fda.gov/medwatch.
You may also report side effects to Genentech at (888) 835-2555.