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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Patient Assistance Solutions Program for Letairis

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: 888-856-7990


ALT PHONE: 866-644-5327
FAX: 888-856-7991
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

Gilead Sciences Letairis LEAP Patient Supoort Enrollment Form

Gilead Sciences Letairis REMS Patient Enrollment and Consent Form

Gilead Sciences Letairis Brochure

 

Medications

  • ambrisentan (Letairis) 
 

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, mailed or downloaded from website
Returning Fax or mail from Doctor's office
Doctor's Action Complete section and sign
Applicant's Action Complete section and sign
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe 3-5 business days
   

Medication

Amount/Supply Up to 30 day supply
Sent To Patient's home, unless otherwise noted
Delivery Time Within 2 business days
Refill Process Patient contacts pharmacy
Limit None
Re-application Determined case by case
   

Additional Information

The prescriber must also be enrolled in the program using Letaris Physician Form.

Female patients must first be enrolled in LEAP (Letairis Education and Access Program) in order to access this program.

This program also provides copay assistance.


Updated November 17, 2017


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

Good Days Program

This is a copay assistance program

Provided by: Good Days from CDF

Attn: Enrollment
6900 Dallas Parkway
Suite #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 (pages: 3-5)

Good Days Program Enrollment Information Pages (pages: 1 & 2)

 

Medications

  • ambrisentan (Letairis) 
 

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 Varies
   

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 July 14, 2017