| 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. |
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Valcyte |
View Coupon |
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HealthWell Foundation Copay ProgramThis is a copay assistance program |
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Provided by: HealthWell Foundation |
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PO Box 220410 TEL: 800-675-8416FAX: 800-282-7692 |
Languages Spoken:
English, Others By Translation Service |
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Program Applications and Forms |
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HealthWell Foundation Copay Program: Contact program |
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Medications |
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Eligibility Requirements |
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| 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 |
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| Obtaining | Call or complete online | ||
| Receiving | Sent out or may be completed online | ||
| Returning | |||
| 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 |
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| 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 |
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| 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. |
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| Updated January 03, 2018 | |||
| 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 |
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Genentech Access to Care Foundation (HIV & Transplants) |
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Provided by: Genentech, Inc. |
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PO Box 29064 TEL: 888-754-7651FAX: 800-305-1830 |
Languages Spoken:
English |
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Program Applications and Forms |
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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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Genentech Insurance Attestation-Patients Form: Cellcept |
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Genentech Insurance Attestation-Patients Form: 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 | FDA-approved diagnosis | ||
| 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 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 |
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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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| Updated February 19, 2018 | |||
