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Patient Access Network Foundation (PAN)
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PO Box 221858
Charlotte, NC 28222
Phone
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(866)316-7263
Fax:
(866)316-7263
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Eligibility
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This is a copay assistance program for patients that have health insurance. The patient's insurance must cover the qualifying medication that they are seeking assistance for. Patient with Medicare Part D will be considered on a case by case basis. Patients must be at or below 400-500% of the federal poverty level, must have a medically appropriate diagnosis/condition and must reside and receive treatment in the US. |
| Who Can Apply
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Patients or healthcare providers can complete the application online or by phone. |
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Required
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Patients must call for information or inform their doctor that they are in need. Doctors action will be discussed with the patient and doctor after the request is received. |
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Supply
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Not applicable |
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Ship To
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Patient sent card to be used at pharmacy |
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Note
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*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.
Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.
Note: All new enrollment is now done electronically or over the phone. Contact program for details. |
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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.
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| Rescriptor Tablets |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form |
(Requires Acrobat Reader) 
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ViiV Healthcare Patient Assistance Program
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,
Phone
:
(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. |
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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.
|
| Rescriptor Tablets |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form ViiV Connect |
| (Requires Acrobat Reader)
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Xubex Pharmaceutical Services
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PO Box 1244
Winter Park, FL 32790-1244
Phone
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866-699-8239
Fax:
407-671-7960
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Eligibility
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Patients may have insurance. There are no income limits for this program. Patients must be a US resident. |
| Who Can Apply
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Anyone requesting assistance can call to request a faxed application or download it from the website. |
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Required
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The doctor needs to provide a prescription to the patient.The patient must fill out a section and sign the application. |
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Supply
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Varies |
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Ship To
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Either Doctor's office or Patient's home |
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Note
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No proof of income is required. Check the website for the exact price.
This service is not currently available in Montana. |
| |
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.
|
| Rescriptor Tablets |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| (Requires Acrobat Reader)
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