Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 2.
Scroll down to see them all.
 

Valcyte

View Coupon View Coupon

HealthWell Foundation Copay Program

This is a copay assistance program

Provided by: HealthWell Foundation

PO Box 220410
Chantilly, VA 20153-0410

TEL: 800-675-8416


FAX: 800-282-7692
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

 HealthWell Foundation Copay Program: Contact program

 

Medications

  • Valcyte (valganciclovir)
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Varies
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside in the US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified in writing
Decision Timeframe 3-5 business days
   

Medication

Amount/Supply Not applicable
Sent To Varies
Delivery Time Not specified
Refill Process Good for one year
Limit Not specified
Re-application New application every 12 months
   

Additional Information

This program provides financial assistance to eligible individuals to cover coinsurance, copayments, healthcare premiums and deductibles for certain treatments. Also, for those who are eligible for health insurance, but cannot afford the insurance premium, the foundation may be able to help by paying some or all of the medical portion of insurance premiums. The patient is being treated for a specific disease for which funding is available and has insurance that covers the treatment for this disease.

Call for most recent medications as the list is subject to change.
Updated November 18, 2016


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 2.
 

Valcyte

View Coupon View Coupon

Genentech Access to Care Foundation (HIV & Transplants)

Provided by: Genentech, Inc.

PO Box 29064
Phoenix, AZ 85038

TEL: 888-754-7651


FAX: 800-305-1830
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Genentech Patient Auth. and Notice of Release of Information (PAN): Cellcept & Valcyte

Genentech Patient Auth. and Notice of Release of Information (PAN): Cellcept & Valcyte (Spanish)

Genentech Statement of Medical Necessity: Cellcept

Genentech Statement of Medical Necessity: Valcyte

Genentech Insurance Attestation-Patients Form: Cellcept

Genentech Insurance Attestation-Patients Form: Valcyte

 

Medications

  • Valcyte oral solution (valganciclovir)
  • Valcyte tablet (valganciclovir)
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage or been denied coverage
Those with Part D Eligible? Determined case by case
Income Gross annual household income at or below $100,000
Diagnosis/Medical Criteria Not disclosed
US 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 Faxed, mailed or downloaded from website
Returning Fax or mail
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 Patient's home, doctor's office, hospital or pharmacy
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application New application yearly
   

Additional Information


Updated November 03, 2016