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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ViiV Healthcare Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: ViiV Healthcare

ViiVConnect Enrollment
PO Box 220100
Charlotte, NC 28222-0100

TEL: 844-588-3288


FAX: 844-208-7676 		Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

ViiV Healthcare Patient Assistance ViiVConnect Enrollment Form

ViiV Healthcare Patient Assistance ViiVConnect Enrollment Form (Spanish)

HIV Common Application: ViiV Healthcare
 

Medications
  • abacavir sulfate oral solution (Ziagen) Oral Solution
 

Eligibility Requirements   
Insurance Status *Contact program for details.
Those with Part D Eligible? Yes, but contact program for details
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 or Fax in prescription
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient and Doctor are notified
Decision Timeframe Varies
   

Medication
Amount/Supply Contact the program for more details.
Sent To Patient's home, unless otherwise noted
Delivery Time Varies
Refill Process Contact program for details.
Limit Up to one year
Re-application Contact program for details.
   

Additional Information
*Contact ViiV Connect for additional information at (844) 588-3288 or www.viivconnect.com

Medicare Part B, Part D and Medicare Advantage plan patients who need medicine that same day should ask their Patient Representative (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 B, Part D and Medicare Advantage prescription drug plan must 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 20, 2023


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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Good Days Program

This is a copay assistance program

Provided by: Good Days from CDF

Attn: Enrollment
2611 Internet Blvd.
Suite 105
Frisco, TX 75034

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)

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

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

Medications
  • abacavir sulfate (Ziagen) 
 

Eligibility Requirements   
Insurance Status Must have insurance
Those with Part D Eligible? Not specified
Income At or below 500% of FPL
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Yes and have social security number
   

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 Contact the program for details
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 March 22, 2023


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

Patient Access Network Foundation (PAN)

This is a copay assistance program

Provided by: Patient Access Network Foundation


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
 

Medications
  • abacavir sulfate (Ziagen) 
 

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 FDA Approved Diagnosis - See Program Website for Details
US Residency Required? Must reside and receive treatment in US
   

Application
Obtaining Call or complete online
Receiving Complete online or by phone
Returning Not applicable
Doctor's Action Varies
Applicant's Action Call for information or inform doctor that he/she is in need
Decision Communicated Patient and Doctor are notified
Decision Timeframe Within 48 hours
   

Medication
Amount/Supply Not applicable
Sent To Patient is sent savings 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 05, 2023