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-HBV

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-HBV (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 2 of 3.
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Epivir-HBV

Bridges to Access

Provided by: GlaxoSmithKline

PO Box 29038
Phoenix, AZ 85038-9038

TEL: 866-728-4368


FAX: 1-855-474-3063
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

 Bridges to Access Application: Contact program

 

Medications

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

Eligibility Requirements   

Insurance Status Must have no prescription coverage
Those with Part D Eligible? No
Income At or below 250% of FPL
Diagnosis/Medical Criteria Not required
US Residency Required? Must live in one of the 50 states, the District of Columbia, or Puerto Rico and utilize the US healthcare system
   

Application

Obtaining Call or download from Programs website
Receiving Faxed, mailed or downloaded from Programs website
Returning Fax or Mail. (Note: faxed prescriptions are only valid if faxed directly from a prescriber's office. Submit COPIES of Proof of Household income documents. Do not mail original income or tax documents. Documents submitted can not be returned.)
Doctor's Action Fax in prescription
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified in writing
Decision Timeframe Within 2-3 days
   

Medication

Amount/Supply Up to 90 day supply
Sent To Patient's home, doctor's office, or the advocate's facility
Delivery Time Not specified
Refill Process Patient must contact company
Limit Not specified
Re-application New application yearly
   

Additional Information

Patients may apply on their own or with the help of an advocate. Fax or mail enrollment documents to the program with patient name and date of birth on each page (faxed prescriptions are only valid if faxed directly from a prescriber's office). Eligible patients may receive 90 day supply of medicine to their home within 7 days of faxed enrollment (mailed enrollments may take longer to receive medicine).
If enrollment documents are submitted by mail, submit ONLY COPIES of Proof of Household Income documents. Do not mail original income or tax documents. Documents submitted cannot be returned.

Please visit www.BridgesToAccess.com for more information.

This program does not constitute health insurance.

Updated March 11, 2016


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

Epivir-HBV

GSK Access

Provided by: GlaxoSmithKline

PO Box 52046
Phoenix, AZ 85072-2046

TEL: 866-518-4357


FAX: 866-518-3994
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

 GSK Access Application: Contact program

 

Medications

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

Eligibility Requirements   

Insurance Status Must have Medicare Part D
Those with Part D Eligible? Yes, Must have Medicare Part D
Income At or below 250% of FPL
Diagnosis/Medical Criteria Not specified
US Residency Required? Must live in one of the 50 states, the District of Columbia, or Puerto Rico and utilize the US healthcare system
   

Application

Obtaining Call or download from Programs website
Receiving Faxed, mailed or downloaded from Programs website
Returning Fax or Mail. (Note: faxed prescriptions are only valid if faxed directly from a prescriber's office. Submit COPIES of Proof of Household income documents. Do not mail original income or tax documents. Documents submitted can not be returned.)
Doctor's Action Give prescription to patient
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient notified in writing
Decision Timeframe Within 2-3 days
   

Medication

Amount/Supply Up to 90 day supply
Sent To Patient's home
Delivery Time Not specified
Refill Process Patient must contact company
Limit Not specified
Re-application New application yearly
   

Additional Information

If enrollment documents are submitted by mail, submit ONLY COPIES of Proof of Household Income documents. Do not mail original income or tax documents. Documents submitted cannot be returned.

This program does not constitute health insurance.


Updated March 11, 2016