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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Epivir

ViiV Healthcare Patient Assistance Program

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

Provided by: ViiV Healthcare

PO Box 52037
Phoenix, AZ 85072

TEL: 877-784-4842


FAX: 877-784-4004
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

ViiV Healthcare Patient Assistance Program Application

HIV Common Application: ViiV Healthcare

 

Medications

  • Epivir oral solution (lamivudine)
  • Epivir tablet (lamivudine)
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage or have spent $600 on drugs in current year with Part D
Those with Part D Eligible? Yes
Income At or below 500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must live in US, DC or Puerto Rico
   

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, sign, attach a copy of proof of income
Decision Communicated Patient notified in writing
Decision Timeframe Not specified
   

Medication

Amount/Supply Up to 90 day supply
Sent To Patient's home
Delivery Time Not specified
Refill Process Patient must contact company
Limit One year
Re-application Those with Medicare Part D reapply after spending $600 on prescription medication each year, all others reapply on anniversary date of when they enrolled
   

Additional Information

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.


Updated February 15, 2016


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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Epivir

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) General Brochure

 

Medications

  • Epivir (lamivudine)
 

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 April 12, 2016


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

Epivir

Good Days Program

This is a copay assistance program.

Provided by: Good Days from CDF

6900 dallas Parkway
Ste. 200
Plano, TX 75024

TEL: 877-968-7233


FAX: 214-570-3621
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Good Days Program Patient Enrollment Application 2016 (pages: 3-5)

Good Days Program Enrollment Information Pages for 2016 (pages: 1, 2 & 6)

 

Medications

  • Epivir (lamivudine)
 

Eligibility Requirements   

Insurance Status Not specified
Those with Part D Eligible? Not specified
Income Not disclosed
Diagnosis/Medical Criteria Not specified
US Residency Required? Not specified
   

Application

Obtaining Call, download or apply online
Receiving Faxed, mailed or downloaded from website
Returning Fax, mail or submit online
Doctor's Action Give prescription to patient
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient and/or Doctor are notified
Decision Timeframe Not specified
   

Medication

Amount/Supply Not specified
Sent To Not specified
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Must re-enroll at end of calendar year
   

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.
Updated November 24, 2015