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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. |
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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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| Combivir Tablets |
| Epivir Oral Suspension |
| Epivir Tablets |
| Epzicom Tablets |
| Lexiva oral suspension |
| Lexiva Tablets |
| Rescriptor Tablets |
| Retrovir Capsules |
| Retrovir Syrup |
| Selzentry Tablets |
| Tivicay tablet |
| Triumeq tablet |
| Trizivir Tablets |
| Viracept Oral Powder |
| Viracept Tablets |
| Ziagen Oral Solution |
| Ziagen 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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