• *Required.
  • 1. Patient Information

  • One phone number is required.*
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  • 2. Healthcare Provider Information

  • V-Go Customer Care may contact the office if additional information is needed or further action required.
  • 3. Primary Insurance - Medical

  • Please provide accurate information to help expedite your request for support.

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  • 4. Primary Insurance - Pharmacy

  • Please provide accurate information to help expedite your request for support.

  • 5. Other Insurance Information

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  • While we cannot guarantee your insurance company will pay for V-Go supplies, we will call them on your behalf to understand if you can fill your prescription at the pharmacy or through other stores as designated by your medical insurance. Please remember that Valeritas respects your privacy and will not share, rent or sell your personal information except as authorized by you. By signing, you appoint Valeritas as your agent for the purposes of (i) gathering medical and insurance coverage information on your behalf, (ii) following up directly with your insurer to find out if the V-Go is being reimbursed, (iii) what steps you’ll need to take to fill your prescription, and (iv) other purposes described above. You may be contacted if further details are needed.