Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 4.
Scroll down to see them all.
 

Atripla

View Coupon View Coupon

Advancing Access Program

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

Provided by: Gilead Sciences, Inc.

PO Box 13185
La Jolla, CA 92039-3185

TEL: 800-226-2056


FAX: 800-216-6857
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

Gilead Advancing Access Enrollment Form

HIV Common Application: Gilead Sciences

 

Medications

  • Atripla tablet (efavirenz/emtricitabine/tenofovir disoproxil fumarate)
 

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
Receiving Faxed or mailed
Returning Fax or mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe 3-5 business days
   

Medication

Amount/Supply Varies. *see below for details
Sent To Varies. *see below for details
Delivery Time Within 2 business days
Refill Process Patient contacts pharmacy
Limit Not specified
Re-application Varies
   

Additional Information

Insurance benefits, claims assistance and/or other reimbursement help is offered.

If the application is for Vistide, then prescription must be included because it will be sent to the doctor's office. The other medications are given using a pharmacy card. This program is for outpatient use only.

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.


Updated June 14, 2016


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 4.
Scroll down to see them all.
 

Atripla

View Coupon View Coupon

BMS3assist Co-Pay Assist for Atripla, Evotaz, 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


FAX: 888-281-8985
Languages Spoken:

English

Program Website

 

Program Applications and Forms

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

 

Medications

  • Atripla tablet (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? Must reside in the US, Puerto Rico or the USVI
   

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

Eligible patients may be able to save up to $7,500 per year with no monthly limit.

Patient Assistance Program also available; Contact program for details.


Updated June 16, 2016


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 4.
Scroll down to see them all.
 

Atripla

View Coupon View Coupon

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


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

 Patient Access Network Foundation (PAN) Application: Contact program

Patient Access Network Foundation (PAN) Provider Brochure

Patient Access Network Foundation (PAN) Patient Brochure

 

Medications

  • Atripla (efavirenz/emtricitabine/tenofovir disoproxil fumarate)
 

Eligibility Requirements   

Insurance Status *See Additional Information section below
Those with Part D Eligible? Determined case by case
Income Between 400-500% 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 Complete online or by phone
Returning Complete online or by phone
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Call for information or inform doctor that he/she is in need
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

*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.




Updated June 15, 2016


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 4 of 4.
 

Atripla

View Coupon View Coupon

Xubex Patient Assistance Program

This program provides medication at low cost. (Most brand names are provided for reference purposes only.)

Provided by: Xubex

PO Box 1244
Winter Park, Fl 32790-1244

TEL: 866-699-8239


ALT PHONE: 407-478-2663
FAX: 407-671-7960
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Xubex Patient Assistance Program Registration Form (pages 1 & 2)

Xubex Patient Assistance Program Physician Order Sheet (page 3)

 

Medications

  • Atripla tablet (efavirenz/emtricitabine/tenofovir disoproxil fumarate)
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income No limits
Diagnosis/Medical Criteria Not specified
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
Doctor's Action Give prescription to patient
Applicant's Action Complete section and sign
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Varies
Sent To Doctor's office or patient's home
Delivery Time Within 10 days
Refill Process Automatically sent out
Limit Varies per medication
Re-application New application, new documentation yearly
   

Additional Information

No proof of income is required. Check the website for the exact price.

This service is not currently available in Montana.


Updated May 18, 2016