| 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. |
Updated January 13, 2015 | ||
Valcyte |
View Coupon |
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Genentech Access to Care Foundation (HIV & Transplants)This program provides brand name medications at no or low cost. |
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Provided by: Genentech, Inc. |
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PO Box 29064 TEL: 888-754-7651ALT PHONE: FAX: 800-305-1830 |
Languages Spoken:
English |
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Patient Assistance Applications |
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Genentech Patient Auth. and Notice of Release of Information (PAN); Cellcept & Valcyte |
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Genentech Patient Auth. and Notice of Release of Information (PAN); Cellcept & Valcyte (Spanish) |
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Genentech Statement of Medical Necessity - Cellcept |
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Genentech Statement of Medical Necessity - Valcyte |
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Medications |
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Eligibility Requirements |
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| 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 |
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| Obtaining | Doctor/Doctor's office starts process by filling out Statement of Medical Necessity Form | ||
| 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 |
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| 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 |
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| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 2 of 2. | Updated January 08, 2015 | ||
Valcyte |
View Coupon |
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Patient Access Network Foundation (PAN)This is a copay assistance program. |
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Provided by: Patient Access Network Foundation |
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PO Box 221858 TEL: 866-316-7263ALT PHONE: FAX: 866-316-7261 |
Languages Spoken:
English, Spanish, Others By Translation Service |
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Patient Assistance Applications |
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PAN Brochure |
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PAN Eligibility Criteria and Benefit Cap Information |
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PAN Proof of Expenditure Form |
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Medications |
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Eligibility Requirements |
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| Insurance Status | Must have insurance | ||
| Those with Part D Eligible? | Determined case by case | ||
| Income | At or below 500% of FPL | ||
| Diagnosis/Medical Criteria | Medically appropriate condition/diagnosis | ||
| US Residency Required? | Must reside and receive treatment in US | ||
Application |
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| Obtaining | Call or complete online | ||
| Receiving | Sent out or may be completed online | ||
| Returning | Fax, mail or submit online | ||
| Doctor's Action | Will be discussed with patient and Doctor after request is received | ||
| Applicant's Action | Complete section and sign | ||
| Decision Communicated | Patient and Doctor notified in writing | ||
| Decision Timeframe | Within 48 hours | ||
Medication |
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| Amount/Supply | Not applicable | ||
| Sent To | Patient sent card to be used at pharmacy | ||
| Delivery Time | Once approved; shipped same day | ||
| Refill Process | Patient presents voucher/card to pharmacy for each refill | ||
| Limit | None | ||
| Re-application | New application every 12 months | ||
Additional Information |
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| 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. As of 1/8/2015 Funds for Rheumatoid Arthritis, Psoriatic Arthritis, and Plaque Psoriasis have run out. |
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