Program Contact Info / Application Submission
Program	Atripla Patient Assistance Program
Company	BrsMyrHIV
Form	Download PDF
Address	PO Box 13185, LaJolla, CA 92039-3185
Phone	1-866-290-4767
Fax	1-866-290-4487
Program Details
Details	The patient is sent a pharmacy card to be used once a month. Every year a new application is needed.
Program Requirements
Information	The doctor must fill out a section, sign the application and attach a prescription. The patient must fill out a section, sign the application and attach proof of income and any insurance information.
Details	Insurance card NOT required Drivers license NOT required Proof of Income required Copy of most recent tax return such as 1040, 1099 required as proof of income Letter from Doctor stating zero income required as proof of income Form 4506T (If taxes were not filed) NOT required as proof of income Most recent bank statements NOT required as proof of income Most recent check/check stub copy required as proof of income Letter from employer required as proof of income Benefits statement for Social Security, Unemployment, Veterans Benefits, Pension/Retirement required as proof of income Award Letter for Alimony/Child Support, Unemployment required as proof of income Notarized statement from patient stating zero income required as proof of income
Delivery of Medication
Ship Time	10-14 business days
Delivery Options	Can NOT be delivered directly to the patient Can NOT be delivered directly to the doctor Shipped as a voucher card
Application Process
App Process	Anyone with the patient's and the doctor's information can call. The application can be either faxed or mailed out upon request. The completed application can be faxed or mailed back. Both the patient and doctor are notified in writing of acceptance or denial. The decision is usually made within 2-3 business days.
New Applications	New applications accepted Patients can apply directly to the program Doctors can apply directly to the program Advocates can apply directly to the program Can NOT apply for a new application via phone Can apply for a new application via fax Can apply for a new application via mail
Refills	Refills accepted
Re-Applications	Re-Applications accepted Patients can apply for Re-Applications Doctors can apply for Re-Applications Advocates can apply for Re-Applications Can NOT Re-Apply via phone Can Re-Apply via fax Can Re-Apply via mail
Appeals	Income Appeals accepted Patients can NOT apply for Income Appeals Doctors can apply for Income Appeals Advocates can apply for Income Appeals Hardship Appeals accepted Patients can NOT apply for Hardship Appeals Doctors can apply for Hardship Appeals Advocates can apply for Hardship Appeals Can NOT apply for an appeal via phone Can apply via fax Can apply for an appeal via mail
Eligibility
Eligibility	The patient must be uninsured or underinsured and meet income guidelines that are not disclosed. The medication must be used for outpatient use only. The patient must also be a US resident with a prescription from a US doctor. This program also has an insurance verification program.
Limitations	Patients may be eligible with existing prescription coverage on a case by case basis Patients may be eligible if prescription is not covered on a case by case basis Patients may be eligible if prescription coverage has been exhausted on a case by case basis Patients may be eligible if they are accepting Medicare on a case by case basis Patients may be eligible if they are accepting Medicare part D on a case by case basis Patients are NOT eligible if the medication is not covered under Medicare Patients may be eligible if Medicare coverage has been exhausted on a case by case basis
Appeals
Conditions	Appeals will consider out-of-pocket expenses Appeals will consider total medical expenses Appeals must be made after the patient has been denied
Other Medications
Other  Medications  available in  this program	Atripla 1100mg - HIV (Generic: efavirenz, emtricitabine, tenofovir)