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Patient Assistance Information

 
6 Programs Sponsored By Gilead Sciences (External Link)
 
 
Gilead Advancing Access

P.O Box 13185
La Jolla, CA 92039-3185
Phone : 800-226-2056
Fax: 800-216-6857
Eligibility
> This program is intended for patients that are uninsured. Medicare Part D patients are not eligible for this program. Income based on FPL. Must be a US resident
Who Can Apply
> Call for application to be faxed or mailed. Return application via fax or mail. Patient and Doctor notified in writing of decision in 3-5 business days.
Required
> Medically appropriate condition/diagnosis required. Doctor must complete and sign application. Patient must complete application, sign, and attach proof of income.
Supply
> Amount/Supply varies. *see below for details. Patient contacts pharmacy for refills. Refill limit not specified. Re-application process not specified.
Ship To
> Varies. *see below for details. Ships within 2 business days.
Note
> Insurance benefits, claims assistance and/or other reimbursement help is offered. If the application is for Vistide, then prescription must be included because it will be sent to the doctor's office. The other medications are given using a pharmacy card. This program is for outpatient use only. This Program participates in the CPAPA. This single common application allows uninsured HIV-positive individuals with low incomes to use one application to apply for multiple assistance programs. IMPORTANT: Send completed CPAPA to the corresponding addresses listed for each company.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Atripla tablet
Complera tablet
Descovy
Emtriva capsule
Emtriva oral solution
Genvoya tablet
Hepsera tablet
Odefsey
Stribild tablet
Truvada tablet
Tybost
Viread tablet
Vistide injection
Vitekta tablet
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Advancing Access Program
(Requires Acrobat Reader
 
 
Patient Assistance Solutions Program for Letairis

po bOX 13185
La Jolla, CA 92039
Phone : (866)664-5327
Fax: (888)856-7991
Eligibility
> This program is intended for patients that are uninsured. Medicare Part D patients are not eligible for this program. Income based on FPL. Must be a US resident.
Who Can Apply
> Call to have application faxed, mailed or download from website. Application must be returned from Doctor's office via fax or mail. Patient and Doctor notified in writing in 3-5 business days.
Required
> Medically appropriate condition/diagnosis required. Doctor and patient must complete and sign application.
Supply
> Up to 30 day supply. Patient contacts pharmacy for refills. No refill limit. Re-application process determined case by case.
Ship To
> Ship to Patient's home, unless otherwise noted with 2 business days.
Note
> The prescriber must also be enrolled in the program using Letaris Physician Form. Female patients must first be enrolled in LEAP (Letairis Education and Access Program) in order to access this program. This program also provides copay assistance.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Letairis tablet
 
 
 
Cayston Patient Assistance Program

po bOX 13185
La Jolla, CA 92039
Phone : (877)722-9786
Fax: (877)550-1705
Eligibility
> This program is intended for patients that are uninsured. Medicare Part D patients are not eligible for this program. Income based on FPL. Must be a US resident.
Who Can Apply
> Call to have application faxed or mailed. Return application via fax or mail. Patient must complete application, sign and attach proof of income.
Required
> Medically appropriate condition/diagnosis required. Doctor must complete and sign application.
Supply
> Up to 1 month supply. Patient contacts pharmacy. Refill limit not specified. Re-application process not specified. Patient and Doctor notified in writing of decision in 3-5 business days.
Ship To
> Ships to Patient's home, unless otherwise noted within 2 business days.
Note
>
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Altera Nebulizer for Cayston nebulizer system
aztreonam
 
 
 
Support Path Patient Assistance Program


,
Phone : (855)769-7284
Fax: (855)298-8700
Eligibility
> Must be uninsured and be ineligible for federal or state programs; or have a plan design limitation. Medicare Part D patients are not eligible for this program. Income must be a or below 500% of FPL* (see below). Must reside permanently in the US or US territories.
Who Can Apply
> Call to have application faxed, mailed or download from website. Return application via fax or mail. A decision will be received by phone or mail in 2 business days, once application process is complete.
Required
> Diagnosis/Medical Criteria *See Additional Information section below. Doctor must complete and sign application. Patient must complete application, sign, attach proof of income and any insurance information.
Supply
> Up to a 28 day supply. Company contacts patient to arrange refills. 2 enrollments per lifetime. Re-application process determined case by case.
Ship To
> Ship to Doctor's office or patient's home within 2-3 business days.
Note
> *500% FPL or less than $100k for the household This program also provides copay assistance. Patient must be diagnosed with Chronic Hepatitis C.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Harvoni tablet
Sovaldi tablet
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Support Path Patient Assistance Program
(Requires Acrobat Reader
 
 
Truvada for PrEP

PO Box 13185
La Jolla, CA 92039
Phone : (800)226-2056
Fax:
Eligibility
> This program is intended for patients that are uninsured. Medicare Part D patients are not eligible for this program. Income based on FPL. Not intended for HIV+ applicants (for preventative purposes only). Must be a US resident.
Who Can Apply
> Call to have application faxed, mailed or download from website. Patient and Doctor notified of decision in writing within 3-5 business days.
Required
> Doctor must complete and sign application. Patient must complete application, sign and attach proof of income.
Supply
> Up to 1 month supply. Patient contacts pharmacy fro refills. Refill limit not specified. New application must be completed every 6 months.
Ship To
> Shipping to location varies, is received within 2 business days.
Note
> Truvada for PrEP is now covered under the Gilead Sciences, Advancing Access Program.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Truvada tablet
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Truvada for PrEP
(Requires Acrobat Reader
 
 
AccessConnect for Zydelig


,
Phone : (844)622-2377
Fax: (855)553-8672
Eligibility
> Must have no prescription coverage for needed medication. Medicare Part D patients are eligible, but contact program fro details. Income requirements not disclosed. Must be a US resident and treated by a US licensed healthcare provider.
Who Can Apply
> Call for prescreening and have application faxed. Return application via fax. Call for decision which could take up to 10 days.
Required
> Diagnosis/medical criteria required to be medically Necessary as determined by a Doctor. Doctor must complete and sign application. Patient must complete application, sign, attach copies of proof of income, residency and other requested documentation.
Supply
> Up to 30 day supply. Patient contacts pharmacy for refills. Contact the program for refill limit details. New application to be completed yearly.
Ship To
> Ships to Patient's home within 4-10 business days.
Note
> The ZYDELIG QuickStart Program provides a free 30-day supply for eligible patients who face an insurance coverage delay of more than 5 business days. This program also provides copay assistance for insured patients.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Zydelig tablet