| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 1 of 3. 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 03, 2021 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 2 of 3. Scroll down to see them all. |
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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 June 21, 2021 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 3 of 3. | |||
HealthWell Foundation Copay ProgramThis is a copay assistance program |
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Provided by: HealthWell Foundation |
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PO Box 489 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 Enrollment: Contact program |
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HealthWell Foundation COVID-19 Ancillary Costs: 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 | FDA Approved Diagnosis - See Program Website for Details | ||
| 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 October 07, 2021 | |||
