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GlaxoSmithKline Bridges to Access Program
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PO Box 29038,Phoenix, AZ 85038-9038
Phoenix, AZ 85038-9038
Phone
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866-728-4368
Fax:
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Eligibility
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The patient must have no prescription coverage for the requested medication and have an income at or below 250% of the Federal Poverty Level. The patient must also be a US resident. |
| Who Can Apply
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The patient advocate can call for an application or start the application process on line. |
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Required
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The doctor must fill out a section, sign the application and attach a prescription.The patient must fill out a section, sign the application, and attach proof of income and any denial letters from insurance companies. |
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Supply
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Ship To
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Patient's home advocate |
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Note
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The patient advocate can call for an application or start the application process on line. |
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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.
| | Ziagen Tablets |
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Orange Card
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Orange Card
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Phone
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(888) 672-6436
Fax:
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Eligibility
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Seniors age 65 and older and the disabled enrolled in Medicare with annual income below $30,000 single/$40,000 couple (approximately 300% of poverty) and patient must not have public or private insurance coverage for prescription medicines.
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| Who Can Apply
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Patient should call for application. |
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Required
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Minimal information is required. |
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Supply
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Ship To
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Note
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Discounts are 25% off the wholesale list price of GlaxoSmithKline outpatient drugs. Participating pharmacies charge card holders no more than a negotiated price. GlaxoSmithKline expects card holders to realize average savings of 30-40% off retail prices.
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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.
| | Ziagen Tablets |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form Application Form | (Requires Acrobat Reader) 
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ViiV Healthcare Patient Assistance Program
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Phone
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(844)588-3288
Fax:
(844)208-7676
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Eligibility
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Patients must have no prescription coverage or have spent $600 on drugs in current year with Medicare Part D. Patients must be at or below 500% of the Federal Poverty Level, have a medically appropriate diagnosis/condition and must live in the US, Washington DC or Puerto Rico. |
| Who Can Apply
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Anyone interested can call to have an application faxed, mailed or download one. For additional information please visit https://www.viivconnect.com/ |
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Required
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Doctors must provide the patient with a prescription. Patients must complete the application, sign and attach proof of income. The application can then be faxed or mailed. |
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Supply
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Up to 90 day supply |
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Ship To
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Patient's home |
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Note
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Non Medicare Part D patients who need medicine that same day should ask their Advocate (ie, anyone involved in the delivery of the patient's healthcare and is not a family member or friend) to enroll them in ViiV Healthcare PAP by phone. Patients enrolled in a Medicare Part D prescription drug plan must first apply via mail or fax and be found eligible before medicine can be shipped.
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.
| | Ziagen Tablets |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form ViiV Connect | | (Requires Acrobat Reader)
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