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

Valcyte

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Genentech Access to Care Foundation (HIV & Transplants)

This program provides brand name medications at no or low cost.

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 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

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 May 01, 2015