Join the Valcyte® $15 Co-pay Card Program

For eligible commercial patients, the Valcyte® $15 Co-pay Card can help reduce their out-of-pocket costs to $15 per monthly co-pay, regardless of their income level.

If you’ve been prescribed brand-name Valcyte or you are enrolling on behalf of a patient, please complete the form below.


Step 1 of 2: Check patient eligibility

Valcyte® $15 Co-pay Card Terms and Conditions

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  1. Are you 18 years of age or older?
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  2. For what has brand-name Valcyte been prescribed for?
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  3. Does the patient have commercial insurance? (Like the type you get through an employer or directly from an insurance company. Healthcare exchange plans that are offered through the Affordable Care Act are considered commercial insurance.)
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  4. What is the patient’s state (or territory) of residence?
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  5. Is the patient receiving free drug assistance through the Genentech® Access to Care Foundation (GATCF) or any other charitable organization?
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  6. Is the patient a government beneficiary and/or enrolled in any state- or federally funded healthcare program, including but not limited to all Medicare, Medicaid, Medigap, VA, DoD, or TRICARE? We may contact the patient by phone or mail periodically in order to verify that the patient's eligibility for the program has not changed.
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By using the Valcyte® $15 Co-pay Card Program, the patient acknowledges and confirms that, at the time of usage, (s)he is currently eligible and meets the criteria set forth in the terms and conditions described.

This co-pay card is valid only for patients with commercial (private or non-governmental) insurance who are taking the medication for a Food and Drug Administration (FDA)-approved indication. Patients using Medicare, Medicaid, or any other government-funded program to pay for their medications are not eligible. Patients who start utilizing government coverage during their enrollment period will no longer be eligible for the program.

This Co-pay Card Program is not health insurance or a benefit plan. Distribution or use of the co-pay card does not obligate use or continuing use of any specific product or provider. Patient or guardian is responsible for reporting the receipt of all Co-pay Card Program benefits or reimbursement received to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the Co-pay Card Program, as may be required.

The co-pay card is not valid for medications the patient receives for free or that are eligible to be reimbursed by private insurance plans or other healthcare or pharmaceutical assistance programs (such as Genentech® Access to Care Foundation (GATCF) or any other charitable organization) that reimburse the patient in part or for the entire cost of his/her Genentech medication. Patient, guardian, pharmacist, prescriber, and any other person using the co-pay card agree not to seek reimbursement for all or any part of the benefit received by the recipient through the offer.

The co-pay card will be accepted by participating pharmacies, physician offices, or hospitals. To qualify for the benefits of this Co-pay Card Program, the patient may be required to pay out-of-pocket expenses for each treatment. Once enrolled, this Co-pay Card Program will not honor claims with date of service or medication dispensing that precede program enrollment by more than 120 days. This co-pay card is only available with a valid prescription and cannot be combined with any other rebate/coupon, free trial, or similar offer for the specified prescription. Use of this co-pay card must be consistent with all relevant health insurance requirements and payer agreements. Participating patients, pharmacies, physician offices, and hospitals are obligated to inform third-party payers about the use of the co-pay card as provided for under the applicable insurance or as otherwise required by contract or law. The co-pay card may not be sold, purchased, traded, or offered for sale, purchase, or trade. The co-pay card is limited to 1 per person during this offer period and is not transferable. Program eligibility period is contingent upon patient’s ability to meet and maintain all requirements as set forth by the program. Genentech will periodically verify eligibility and will terminate patients without obligation to pay claims if change to status is detected. This program is not valid where prohibited by law, and shall follow state restrictions in relation to AB-rated generic equivalents where applicable (e.g. MA, CA).

The patient or their guardian must be 18 years or older to receive Co-pay Card Program assistance. This Co-pay Card Program is (1) void if the card is reproduced; (2) void where prohibited by law; (3) only valid in the United States and Puerto Rico; and (4) only valid for Genentech products. Healthcare providers may not advertise or otherwise use the program as a means of promoting their services or Genentech’s products to patients. Genentech reserves the right to rescind, revoke, or amend the program without notice at any time.

Step 2 of 2: Patient Information

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Enter the 9-digit co-pay card ID number on the front of the Valcyte® $15 Co-pay Card.

Step 2 of 2: Patient Information

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Patient already enrolled

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Enroller Information
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Terms and Conditions

*The patient information disclosed during this enrollment, including name, email address, mailing address, and phone number, will be shared with Genentech, the sponsor of the card. In addition, information shared by the patient’s pharmacy/physician, such as the date the patient filled the prescription, the date the medication was administered by the patient’s physician (if applicable), and the amount that the patient will be reimbursed by Genentech, will be shared with Genentech, the sponsor of this card. The patient agrees to be contacted by phone, mail, or email with the information and/or materials about the patient’s Genentech Valcyte® $15 Co-pay Card. For more information, please see the Genentech Privacy Policy at www.gene.com.

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*I have read and agreed (or the patient has read and agreed) to the Terms and Conditions of the Valcyte® $15 Co-pay Card Program.

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Patient Consent

*I give my consent (or I have the patient's consent) to enroll in the Valcyte® $15 Co-pay Card Program.

Valcyte Co-pay Card Image

Success!

The patient is signed up for the
Valcyte® $15 Co-pay Card Program

A printed Valcyte® Co-pay Card will arrive by mail in 5 to 7 business days. But the patient can start benefiting today. Simply click the button below and print out a temporary version of the card.

Print a temporary Valcyte® $15 Co-pay Card

How to use the card

The patient should present the card to the pharmacist:

  • If the patient's pharmacy can store the co-pay card information, he or she may not need to present the card each month
  • If the patient uses a specialty or mail order pharmacy, he or she should provide the co-pay card details over the phone
Valcyte Co-pay Card Image

Success!

The Valcyte® $15 Co-pay Card is successfully activated.

How to use the card:

The patient should present the card to the pharmacist:

  • If the patient's pharmacy can store the co-pay card information, he or she may not need to present the card each month
  • If the patient uses a specialty or mail order pharmacy, he or she should provide the co-pay card details over the phone

We're sorry, but the patient is not eligible for this program

If you believe you have received this message in error, please call 1-877-MY-VAL49 (1-877-698-2549) to speak with an agent.