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 July 18, 2014
 

Atripla

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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 ProgramPO Box 13185
La Jolla, CA 92039-3185

TEL: 866-290-4767


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

English, Others By Translation Service

Program Website

 

Patient Assistance Applications

Atripla Patient Assistance Program Application

HIV Common Application; Bristol-Myers Squibb & Gilead Sciences

 

Medications

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

Eligibility Requirements   

Insurance Status Must be uninsured
Those with Part D Eligible? No
Income Based on FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must be a US resident
   

Application

Obtaining Call or download
Receiving Faxed or mailed
Returning Fax or mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach proof of income
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 1-3 business days
Refill Process Patient must contact company
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.



Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 3.
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Updated October 15, 2014
 

Atripla

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BMS3assist Co-Pay Assist for Atripla, Reyataz and Sustiva

This is a copay assistance program.

Provided by: Bristol-Myers Squibb Company

BMS3assist
PO Box 221430
Charlotte, NC 28222

TEL: 888-281-8981


ALT PHONE:
FAX:
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

BMS3assist Co-Pay Assist for Atripla, Reyataz and Sustiva: Contact program

 

Medications

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

Eligibility Requirements   

Insurance Status Must have insurance
Those with Part D Eligible? No
Income No limits
Diagnosis/Medical Criteria Not specified
US Residency Required? United States or Puerto Rico
   

Application

Obtaining Call
Receiving There is no application
Returning Not applicable
Doctor's Action Not specified
Applicant's Action Request card online or by phone
Decision Communicated Patient notified
Decision Timeframe Decision made during phone screening
   

Medication

Amount/Supply Not applicable
Sent To Varies
Delivery Time ID number given over the phone or card shipped within 7-10 business days
Refill Process Not applicable
Limit Up to one year
Re-application Must re-enroll at end of calendar year
   

Additional Information

The program will help pay for the cost of prescription copays for up to $400 per copay per product for a maximum of 12 monthly copays within 1 year.

This program expires December 31, 2014.


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 3. Updated October 17, 2014
 

Atripla

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Patient Access Network Foundation (PAN)

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/diagnosis
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 and 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.