Don't qualify for this program?
Visit the DBAs to look for financial assistance based on your diagnosis.

Program 1 of 3.
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Updated January 24, 2014
Atripla

Atripla Patient Assistance Program

This program provides brand name medications at no or low cost.

Provided by: Bristol-Myers Squibb & Gilead Sciences

ATRIPLA Patient Assistance Program
PO Box 13185
La Jolla, CA 92039-3185

TEL: 866-290-4767


ALT PHONE:
FAX: 866-290-4487
Languages Spoken:

English

Program Website
 

Patient Assistance Applications

Atripla Patient Assistance Program

HIV Common Application; Bristol-Myers Squibb & Gilead Sciences

 

Medications

  • Atripla Tablet dosage varies (efavirenz/emtricitabine/tenofovir)
 

Eligibility Requirements

Insurance Status Must be uninsured or underinsured
Those with Part D Eligible? Yes
Income Based on FPL
Diagnosis/Medical Criteria Medically appropriate condition
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Faxed or mailed
Returning Fax
Doctor's Action Complete section, sign
Applicant's Action Complete section, sign, attach proof of income and any insurance information
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe 3-5 business days
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Card activated on next business day after approval
Refill Process Good for one year
Limit Not specified
Re-application New application yearly
   

Additional Information

Medication is for outpatient use only. Insurance benefits, claims assistance and/or other reimbursement help is offered.

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.

Contact program for Spanish application.



Don't qualify for this program?
Visit the DBAs to look for financial assistance based on your diagnosis.

Program 2 of 3.
Scroll down to see them all.
Updated April 08, 2014
Atripla

Co-Pay Assistance Card Program

This is a copay assistance program.

Provided by: Gilead Sciences


TEL: 877-505-6986


ALT PHONE:
FAX:
Languages Spoken:

English

 

Patient Assistance Applications

 Co-Pay Assistance Card Program: Contact program

 

Medications

  • Atripla Tablet dosage varies (efavirenz/emtricitabine/tenofovir disoproxil fumarate)
 

Eligibility Requirements

Insurance Status Must not have public insurance, may have private insurance
Those with Part D Eligible? No
Income No limits
Diagnosis/Medical Criteria Not required
US Residency Required? Must be citizen
   

Application

Obtaining Call for prescreening
Receiving There is no application
Returning Not applicable
Doctor's Action Give prescription to patient
Applicant's Action The patient responds to questions over the phone to verify eligibility
Decision Communicated Decision made during phone screening
Decision Timeframe Not applicable
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Not applicable
Refill Process Good for one year
Limit Not applicable
Re-application This is a one time program
   

Additional Information

Truvada, Viread & Emtriva: This program will cover up to the first $200 of the patient's copay each month for 12 months from the date the card is activated, up to a maximum of $2400 www.truvada.com

Stribild, Complera & Atripla: This program will cover $400 of a 30 day supply for up to $4,800 per calendar year. Patient must have prescription coverage. www.stribild.com

The Program will not accept new enrollees after December 31, 2015



Don't qualify for this program?
Visit the DBAs to look for financial assistance based on your diagnosis.

Program 3 of 3. Updated January 30, 2014
Atripla

Patient Access Network Foundation

This is a copay assistance program.

Provided by: Patient Access Network Foundation

PO Box 221858
Charlotte, NC 28222-1858

TEL: 866-316-7263


ALT PHONE:
FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website
 

Patient Assistance Applications

PAN Brochure

PAN Eligibility Criteria and Benefit Cap Information

PAN Proof of Expenditure Form

 

Medications

  • Atripla Tablet 600mg/200mg/300mg (efavirenz/emtricitabine/tenofovir disoproxil fumarate)
 

Eligibility Requirements

Insurance Status Must have insurance
Those with Part D Eligible? Determined case by case
Income At or below 500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Fax, mail or submit online
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Complete section, sign
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved ; shipped same day.
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months
   

Additional Information

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.