| 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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Genentech Access to Care Foundation (GATCF) ValcyteThis 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: 888-754-7651FAX: 800-305-1830 |
Languages Spoken:
English, Spanish, Others By Translation Service |
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Program Applications and Forms |
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Genentech Access to Care Foundation (Valcyte): Patient Auth. and Notice of Release (PAN) |
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Genentech Access to Care Foundation (Valcyte): Patient Auth. and Notice of Release (PAN) Spanish |
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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 | Uninsured or Underinsured | ||
| Those with Part D Eligible? | Determined case by case | ||
| Income | Not disclosed | ||
| Diagnosis/Medical Criteria | Medically appropriate condition/diagnosis | ||
| US Residency Required? | Must be treated in the US or Puerto Rico | ||
Application |
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| Obtaining | Call or download | ||
| Receiving | Faxed or downloaded from website | ||
| Returning | Fax or submit online | ||
| Doctor's Action | Complete section, sign, attach required documents | ||
| Applicant's Action | Complete section, sign, attach required documents | ||
| Decision Communicated | Doctor notified | ||
| Decision Timeframe | Varies | ||
Medication |
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| Amount/Supply | Amount requested is sent | ||
| Sent To | Varies | ||
| Delivery Time | Contact Program for Details | ||
| Refill Process | Contact program for details. | ||
| Limit | Contact the program for details | ||
| Re-application | New application every 12 months | ||
Additional Information |
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| Eligibility determined on a case-by-case basis. Contact program for details. |
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| Updated September 09, 2020 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 2 of 2. | |||
Good Days ProgramThis is a copay assistance program |
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Provided by: Good Days from CDF |
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Attn: Enrollment TEL: 877-968-7233FAX: 214-570-3621 |
Languages Spoken:
English |
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Program Applications and Forms |
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Good Days Program Patient Enrollment Application (pages 3-5) |
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Good Days Program Enrollment Information Pages (pages 1 & 2) |
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Good Days Program Patient Enrollment Application (pages 3-5) (Spanish) |
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Good Days Program Enrollment Information Pages (pages 1 & 2) (Spanish) |
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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? | Not specified | ||
| Income | At or below 500% of FPL | ||
| Diagnosis/Medical Criteria | FDA-approved diagnosis | ||
| US Residency Required? | Yes and have social security number | ||
Application |
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| Obtaining | Call, download or apply online | ||
| Receiving | Faxed, mailed or downloaded from website | ||
| Returning | Fax, mail or submit online | ||
| Doctor's Action | Give prescription to patient | ||
| Applicant's Action | Complete section, sign, attach required documents | ||
| Decision Communicated | Patient and/or Doctor are notified | ||
| Decision Timeframe | Varies | ||
Medication |
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| Amount/Supply | Not specified | ||
| Sent To | Not specified | ||
| Delivery Time | Not specified | ||
| Refill Process | Not specified | ||
| Limit | Not specified | ||
| Re-application | Must re-enroll at end of calendar year | ||
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. |
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| Updated September 10, 2020 | |||
