Fillable COMMON PATIENT ASSISTANCE PROGRAM APPLICATION (HIV)

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COMMON PATIENT ASSISTANCE PROGRAM APPLICATION (HIV)

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COMMON PATIENT ASSISTANCE PROGRAM APPLICATION (HIV)
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Program Description
The purpose of this enrollment tool is to collect information that numerous pharmaceutical companies and foundations providing the donated
products of pharmaceutical companies require for enrollment in various HIV patient assistance programs (PAPs). These PAPs provide medicines at
little or no cost to eligible patients. To facilitate enrollment in multiple PAPs, this tool consolidates all of the necessary information in one place. In
each instance in which the tool refers to “PAPs” it means all of the PAPs for which the applicant may be eligible. Each PAP will determine a patient’s
eligibility for assistance based on their individual program requirements.
Further, each PAP requires its own application and that, once completed, can be printed out multiple times and submitted to individual PAPs with the
required attachments.
Important Information
1. PAPs cannot process incomplete applications.
2. Make sure all required information and accompanying documents are complete and signed before they are submitted to each PAP.
3. Page 2, Patient General Information, line 5: indicate the correct contact for additional follow-up. If none is selected, the default is the provider.
4. Page 2, Coverage Information: respond for each category of coverage.
5. Page 2, Alternate Shipping Information: this address is used if the PAP will ship to a location other than the physician/prescriber. Note that not all
PAPs will ship to an alternate address.
6. Page 2, Advocate Information: indicate if an advocate is applying on behalf of a patient, and be sure to include a signature. If no advocate is
involved, leave this section blank.
7. Page 3, IMPORTANT: check the “Required Attachments” carefully. Different attachments may be required by different PAPs. Especially note
whether an original prescription form is required.
8. Page 4, IMPORTANT: signatures from the patient (or the patient’s legal representative) and the provider are ALWAYS required.
9. IMPORTANT: send completed, signed, Common PAP Applications to the corresponding addresses listed for EACH COMPANY from which
medication is sought.
10. Complete the form using either blue/black pen or via computer, responding to all required questions.
This publication was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS)
under cooperative agreement #U69HA26846 as part of an award totaling $500,000 with zero percentage financed with non-governmental sources. The
contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government.
Patient General Information
Name (First):  _____________________________________________  (Middle):  ____________________________________ (Last):  _________________________________________________
Mailing Address:  _______________________________________________________________  City:  ___________________________________ State:  _______ Zip:  ___________________
Phone:  _____________________________________________  Ok to call?   Yes   No E-mail (optional):  _________________________________________________________ 
Language:  English  Spanish  Other:  ________________________________ Gender:  M  F Date of birth: ___________________________________
U.S. Resident?   Yes   No
Number in Household:  1  2  3  4  5  6  7  8  9 Current Annual Household Income: $  __________________________________
Follow-Up point of contact:  Provider (default)  Caseworker  Patient  Other: ______________________________________________________________________
Coverage Information (check all that apply)
AIDS Drug Assistance Program:
Enrolled Denied Pending Not Applied Not Eligible Waitlisted
Medicaid:
Enrolled Denied Pending Not Applied Not Eligible
Medicare:
Enrolled Denied Pending Not Applied Not Eligible
Medicare Part D:
Enrolled Denied Pending Not Applied Not Eligible
Private Insurance Drug Coverage:
Enrolled Not Enrolled
  If enrolled, Insurer Name: ___________________________________________________
Veterans Administration Health Benefits
Enrolled Not Eligible
Other:
____________________________________________________________________________________________________________________________________________________________
Physician/Prescriber Information
Name (First):  _____________________________________________  (Middle):  ____________________________________ (Last):  _________________________________________________
Business/Facility Name: ____________________________________ Phone: ______________________________________ Fax:  _________________________________________________
Offi Contact Name (First):  __________________________________________________  (M.I.):  __________________ (Last):  _________________________________________________
Mailing Address:  _______________________________________________________________  City:  ___________________________________ State:  _______ Zip:  ___________________
Professional Designation/Specialty:  _______________________________________  National Provider Identifier ______________________________________________________
Tax ID #:  ___________________________________________  DEA #:  ________________________________________ State License #:  _________________________________________
Alternate Shipping Information
(some PAPs require medication to be shipped to physician/prescriber while others will ship to the patient’s alternate shipping address of choice)
Name (First):  _____________________________________________  (Middle):  ____________________________________ (Last):  _________________________________________________
Business/Facility Name: ____________________________________ Phone: ______________________________________ Fax:  _________________________________________________
Shipping Address:  _____________________________________________________________  City:  ___________________________________ State:  _______ Zip:  ___________________
Relationship to patient:  _____________________________________________________  Reason for alternate: ____________________________________________________________
Advocate Information
(if applying on behalf of patient)
Name (First):  _____________________________________________  (Middle):  ____________________________________ (Last):  _________________________________________________
Business/Facility Name: ____________________________________ Phone: ______________________________________ Fax:  _________________________________________________
Street Address:  ________________________________________________________________  City:  ___________________________________ State:  _______ Zip:  ___________________
Relationship to patient:  _________________________________________________________  
_________________________________________________________________________________________________________________  __________________________________________________
Advocate Signature Date
Please send general feedback and questions on the Common Patient Assistant Program Application form to commonPAPform@nastad.org.
For any questions about eligibility and status of a submitted application, please contact the corresponding company
COMMON PATIENT ASSISTANCE PROGRAM APPLICATION (HIV)
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IMPORTANT: Send completed, signed, Common PAP Applications to the corresponding addresses listed for EACH COMPANY from which medication is sought.
AbbVie Patient Assistance Foundation
P.O. Box 270, Somerville, NJ 08876 — Phone: 800-222-6885 Fax: 866-483-1305
Kaletra
®
(lopinavir/ritonavir)
Norvir
®
(ritonavir)
*If there is a need for an urgent delivery of medication, the
health care provider should call the program directly to
discussoptions.
**Original “ink” signature required to complete enrollment.
Nostamped signatures are accepted.
App. submitted via  
Fax  Mail
Ship to Physician
Attachment Req.: 6; If insured but
cannot affor treatment: 4 & 5
Boehringer Ingelheim Cares Foundation Inc.
Patient Assistance Program c/o Express Scripts SDS, Inc.
P.O. Box 66745, St. Louis, MO 63166 — Phone: 800-556-8317 Fax: 866-851-2827
Aptivus
®
(tipranavir)
Viramune XR
®
(nevirapine)
*Once an application is received, the patient can expect to
receive medicine within 48 hours.
**Original “ink” signature required to complete enrollment.
Nostamped signatures are accepted.
App. submitted via  
Fax  Mail
Ship to Physician
Attachment Req.: 2; 5 if Part D
enrollee
Bristol-Myers Squibb: BMS3assist Program
P.O. Box 221430, Charlotte, NC 28222-1430 — Phone: 888-281-8981 Fax: 888-281-8985
Evotaz
®
(atazanavir/cobicistat)
Reyataz
®
(atazanavir sulfate)
Sustiva
®
(efavirenz)
*Original “ink” signature required to complete enrollment.
Nostamped signatures are accepted.
App. submitted via  
Fax  Mail
Applications submitted via fax MUST
be from a physician’s offi with a
cover note.
Attachment Req.: 1, 2 or 3; 4, 5 & 6
Gilead Advancing Access: Reimbursement Solutions for Patients in Need
P.O. Box 13185, La Jolla, CA 92039 — Phone: 800-226-2056 Fax: 800-216-6857
Atripla
®
(efavirenz/emtricitabine/tenofovir disoproxil fumarate)
Biktarvy
®
(bictegravir/emtricitabine/tenofovir alafenamide)
Complera
®
(emtricitabine/rilpivirine/tenofovir disoproxil fumarate)
Descovy
®
(Emtricitabine, Tenofovir Alafenamide)
Emtriva
®
(emtricitabine)
Emtriva Oral Solution
®
(emtricitabine oral solution)
Genvoya
®
(elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide)
Odefsey
®
(emtricitabine/rilpivirine/tenofovir alafenamide)
Stribild™ (elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate)
Truvada
®
(emtricitabine and tenofovir disoproxil fumarate)
Tybost
®
(cobicistat)
*Immediate access is available for all products. Patients that are
pre-screened and determined to be eligible for the program
may receive a voucher for the immediate pick-up of a 30-day
supply at the pharmacy of their choice.
**Original “ink” signature required to complete enrollment.
Nostamped signatures are accepted.
App. submitted via  
Fax  Mail
Attachment Req.: 1, 2 or 3; 4 & 5
Johnson & Johnson Patient Assistance Foundation, Inc.
P.O. Box 42796, Cincinnati, OH 45242 — Phone: 800-652-6227 Fax: 888-526-5168
Is the patient currently taking?
Is the patient currently taking?
Is the patient currently taking?
Is the patient currently taking?
Edurant
®
(rilpivirine)
Intelence
®
(etravirine)
Prezista
®
(darunavirc)
Prezcobix
®
(darunavir/cobicistat)
Symtuza
®
(darunavir/cobicistat/
emtricitabine/tenofovir alafenamide)
Is the patient currently taking?
*Immediate access is available through the use of pharmacy
card. At the request of the physician, a pharmacy card number
will be provided to the patient ONLY, immediately upon
eligibility/approval. He/she can then go to the pharmacy with a
valid prescription to pick up their medicine.
**Original “ink” signature required to complete enrollment.
No stamped signatures are accepted.
App. submitted via  
Fax  Mail
Pharmacy Card
Attachment Req: 2, 4, 5 (if Part D
enrollee) & 6
Merck Patient Assistance
P.O. Box 690, Horsham, PA 19044-9926 — Phone: 800-727-5400 Fax: 915-849-1037
Delstrigo™ (doravirine/lamivudine/tenofovir disoproxil fumarate)
Isentress
®
HD
(raltegravir)
Isentress
®
(raltegravir)
Pifeltro™ (doravirine)
*Once a completed application is received, eligible patients can
expect to receive medicine within 24 hours.
**Merck requires both original “ink” signed enrollment tool and
“ink” signed doctor prescription. No copies or stamps are
accepted. If the tool is started by fax, the patient must follow up
by mailing in the original enrollment process and prescription.
***This Program does not accept an advocate signature on
behalf of the patient.
Enrollment form submitted via:
Fax   Mail
Ship to Provider
Ship to Patient
Attachment Req.: 6 & 7
*Faxed applications still require a
follow up hard copy with signature to
be mailed.
THERA Patient Support™
P.O. Box 390, Somerville, NJ 08876 — Phone: 833-238-4372 Fax: 855-836-3069
Trogarzo™ (ibalizumab-uiyk)
Prescription type: New Continuing Therapy Restart
*PAP enrollment requires submission of Trogarzo Enrollment
Form (available at www.trogarzo.com) with completed CPAPA.
Attachments and original “ink” signature required to complete
enrollment.
App. submitted via  
Fax  Mail
Attachment Req.: 1, 2, or 3; 6, 7, 8 & 9
ViiV Healthcare Patient Assistance Program
P.O. Box 220100, Charlotte, NC 28222-0100 — Website: http://www.viivconnect.com
Phone: 1-844-588-3288 (toll-free number) Fax: 1-844-208-7676
Combivir
®
(lamivudine/zidovudine)
Epivir
®
(lamivudine)
Epzicom
®
(abacavir sulfate and lamivudine)
Juluca
®
(dolutegravir/rilpivirine)
Lexiva
®
(fosamprenavir calcium)
Retrovir
®
(zidovudine)
Rukobia
®
(fostemsavir)
Selzentry
®
(maraviroc)
Tivicay
®
(dolutegravir)
Triumez
®
(abacavir/dolutegravir /lamivudine)
Trizivir
®
(abacavir sulfate, lamivudine, and zidovudine)
Viracept
®
(nelfinavi mesylate)
Ziagen
®
(abacavir sulfate)
*In order for the patient or Patient Representative to receive
ViiV Healthcare medication by mail, ViiVConnect must receive a
completed and signed enrollment form and signed prescription.
Medicare Part D PAP applicants must also send proof of Part D
enrollment and proof of spend for $600 or more on out-of-
pocket prescription expenses during the current calendar year.
NOTE: Faxed prescriptions are only valid if faxed directly from a
physician’s office and accompanied by a fax cover sheet.
**Patients who need same-day retail pharmacy access to a ViiV
prescription must be enrolled by a Patient Representative
phone call to ViiVConnect. A Patient Representative may also
help patients apply to ViiVConnect through the ViiVConnect
Provider Portal, by fax or by mail if the patient does not require
same-day access to their prescription.
App. submitted via  
Fax  Mail
Phone
ViiVConnect Portal
Pharmacy Pick-Up
Required attachments: 4, 5, 6 and 7.
Income documentation such as tax
forms are not required to confir
eligibility, as the program completes
an online validation of the patient’s
income. The program will reach out
when circumstances require proof of
income documentation.
ATTACHMENTS: (requirements vary by program) 1. Copy of recent paystub 2. Copy of rst page of most recent Federal income tax return 3. Copy of social security check or awards letter
4. Copy of both sides of insurance card (if Part D or insured) 5. Copy of drug receipts (if Part D or insured) 6. Original prescription form 7. Allergy & Health Information: list of any known
drug allergies and current medications 8. Site of care specications for initial and subsequent dosing (e.g., name and location of infusion center, prescribing physician oce, home
infusion), including authorization for ancillary supplies, as needed (e.g., needles, syringes, etc.) 9. Medication history (complete antiretroviral list along with concomitant medication history
COMMON PATIENT ASSISTANCE PROGRAM APPLICATION (HIV)
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IMPORTANT: This application is not complete unless both the authorization and the certication are signed by the appropriate individuals.
Patient Authorization
By my signature, I authorize each Program and their agents to do the following:
1. Use any information that I provide in my application for the purpose of enrolling in or to administer the PAPs;
2. Contact my doctor, healthcare provider, or pharmacist about my application for the PAPs, and disclose to them information contained in my
application, in order to help me receive Programs’ products under the PAPs and ensure that PAPs’ guidelines are being met;
3. Request information from my insurer, doctor, healthcare provider, or pharmacist about the prescribed medications I receive or will receive
under the PAPs and about my medical condition. This information will be used only to determine my eligibility for the PAPs and to administer
the PAPs. By signing below, I also authorize my insurer, doctor, healthcare provider, or pharmacist to release information about my prescribed
medications and medical condition that is requested by Programs or their agents;
4. Contact my insurer, other potential funding sources, including the Centers for Medicare and Medicaid Services, social workers or patient
advocacy organizations on my behalf in order to determine if I am eligible for health insurance coverage or other funds, and disclose to them
information contained in my PAP applications or information about my prescribed medications and medical condition that has been provided
by my physician, healthcare provider or pharmacist; and
5. Disclose any information obtained from the sources listed above to third parties required by law.
By my signature, I am signifying that I understand the following:
1. Once medical information about me has been disclosed in reliance upon this Authorization, the information may no longer be protected by
federal privacy laws and may be further disclosed; however, Programs agree to protect my information by using and disclosing it only for the
purposes described above or as required by law.
2. Programs and their agents will only ask for the information that is needed to process my application, renew my application or provide me with
help throughout my Program participation. Each Program will only have access to the information needed for that Program and will not have
access to information required for enrollment in any other PAP.
3. This Authorization will remain in effect for as long as I participate in the Program and a period of 5 years after my participation in the Program
ends, and that I am entitled to request a copy of this signed Authorization.
4. I have the right to revoke this authorization at any time by mailing a signed written statement of my revocation to the address(es) used on page
1. Such a revocation would end my eligibility to participate in the PAPs. Revoking this authorization will prohibit disclosures after the date written
revocation is received, except to the extent that action has been taken in reliance on my authorization.
5. Any assistance in the form of product at no cost is contingent upon my ability to meet the eligibility criteria for the Program.
6. The program assistance may change or be discontinued at any time without any notice to me.
7. I agree that the Program does not have any liability in providing PAP services to me.
8. I agree to be bound by the terms and conditions of the Program for which I am deemed eligible and enrolled.
Finally, I understand I may refuse to sign this authorization and that if I refuse, my eligibility for health plan benefit and treatment by my doctor will not
change, but I will not have access to the services available through this program.
If I receive any free product from Programs, I certify that I will not seek reimbursement from any public or private prescription drug plan for the use of
such product.
I certify that the information in this application is complete and accurate to the best of my knowledge and agree to notify PAPs of any change in my
insurance eligibility or financia status within 30 days by providing that information to the address(es) used on page 1.
_________________________________________________________________________________________________________________  __________________________________________________
Signature (Patient or Legal Representative) Date
Physician/Prescriber Certication
By my signature, I certify:
1.
To the best of my knowledge, the information on this patient is correct and complete and consistent with applicable privacy laws and
regulations, and I understand that Program and/or their agents are relying on this representation.
2. I have no knowledge of any intent to sell, barter or give this product to any person other than the patient for whom it has been prescribed.
3. No reimbursement of the cost of product will be accepted by me from public or private sources, including patients, for any treatments where
product will be provided free-of-charge by Program.
4. The medication(s) covered by the PAPs are medically indicated for this patient and that I will be supervising the patient’s treatment.
5. I agree to periodically verify continued use of Programs’ medication and resubmit current prescriptions.
6. My State license is currently in good standing, I am not prohibited from participating in Federally-funded health care programs, nor am I on the
List of Excluded Individuals/Entities maintained by the HHS Offi of Inspector General.
I authorize the Program to forward this prescription to a dispensing pharmacy on behalf of myself and my patient, or to send the medication directly to
the patient, or to send the medication to my offi for dispensing to my patient in accordance with individual program requirements.
_________________________________________________________________________________________________________________  __________________________________________________
Signature Date
COMMON PATIENT ASSISTANCE PROGRAM APPLICATION (HIV)
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Completed 12 April 2021

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