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Program Details

GENENTECH, INC
Genentech Access to Care - CellCept

Valcyte (valganciclovir)
 
CONTACT INFO
Address: PO Box 29064
Phoenix, AZ 85038
Phone: 1-888-754-7651 Provider Phone:
Fax: 1-800-305-1830 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Patient must not have insurance or their health plan has denied coverage.
  • Eligibility for patients with Medicare Part D is determined on a case-by-case basis.
  • Patient must be treated by US licensed healthcare provider.
  • Income at or below: Not Published
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: No
    US citizenship/residency specified: Not Published
    APPLICATION
    Attachments Required: Financial
    Physician License #
    Required:
    Both DEA and State
    NPI
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Provider
    MEDICATION
    Receives: Medication
    Shipped To: Either Provider and Patient
    Quantity in Shipment: Not Published
    Delivery Time: Not Published
    Re-application Policy: New application every 12 months
    Refill Policy: Not Published
    Other Information:

    Last Updated: 01/30/2024

     

     

     


    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.


    Document CellCept Statement of Medical Necessity


    Document Patient Authorization



     

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