Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 2.
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Updated September 16, 2014
 

Trizivir

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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


ALT PHONE:
FAX: 877-784-4004
Languages Spoken:

English, Others By Translation Service

Program Website

 

Patient Assistance Applications

ViiV Healthcare Patient Assistance Program Application

HIV Common Application; ViiV Healthcare

 

Medications

  • Trizivir Tablet dosage varies (abacavir sulfate/lamivudine/zidovudine)
 

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 or DC
   

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.


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 2. Updated October 17, 2014
 

Trizivir

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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

  • Trizivir Tablet 300mg/150mg/300mg (abacavir/lamivudine/zidovudine)
 

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.