advancingaccessconsent.iassist.comGilead Consent

The Gilead Advancing Access ® program is committed to helping you afford your medication every step of the way. If you need assistance with co-pays or paying for your medication, Advancing Access is available to help match you to a program that best meets your financial needs based on your particular circumstances and insurance situation and the eligibility criteria for the programs. Advancing Access may be able to help guide you through the process of understanding the type of insurance you have and alternative coverage if needed. REQUESTED PATIENT SUPPORT OFFERINGS Please select patient support offerings CHECK ALL BOXES THAT APPLY Benefits Investigation Help research and verify specific insurance coverage for Gilead medication Prior Authorization and Appeals Information Provides information to your doctor if your insurance company requires your doctor to complete a Prior Authorization for your Gilead medication. Provides follow up with health insurers regarding the status of your Prior Authorization request and sends updates on information needed. Patient Assistance Program (PAP) or Medication Assistance Program (MAP) Eligibility Screening If you lack insurance coverage and meet the program criteria, you may be eligible to receiveGilead medication free of charge Co-Pay Coupon Program Enrollment If you are eligible, Gilead's Co-Pay Coupon may help lower your out-of-pocket costs. Patients enrolled in government prescription drug programs, such as Medicare Part D and Medicaid are not eligible for the co-pay coupon. To enroll in the Co-pay Coupon Enrollment service, click here and follow the on screen directions or call Advancing Access at 1-800-226-2056 GILEAD MEDICATION PRESCRIBED Product Name * Select One ATRIPLA® (efavirenz/emtricitabine/tenofovir disoproxil fumarate) BIKTARVY® (bictegravir/emtricitabine/tenofovir alafenamide) COMPLERA® (emtricitabine/rilpivirine/tenofovir disoproxil fumarate) DESCOVY® (emtricitabine/tenofovir alafenamide) EMTRIVA® (emtricitabine) GENVOYA® (elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide) ODEFSEY® (emtricitabine/rilpivirine/tenofovir alafenamide) STRIBILD® (elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate) TRUVADA® (emtricitabine/tenofovir disoproxil fumarate) TYBOST® (cobicistat) VEMLIDY® (tenofovir alafenamide) VIREAD® (tenofovir disoproxil fumarate) * If requesting TRUVADA® Please indicate for: Treatment PrEP/Prevention * If requesting DESCOVY® Please indicate for: Treatment PrEP/Prevention PATIENT INFORMATION * Indicates required field. * Patient First Name: * Patient Last Name: * Address: Apt./Unit #: * Zip Code: * City: * State: Select One Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Email: * Preferred Language: * Phone #: SSN (last 4 digits): * DOB: Alternate Contact Name: Alternate Contact Phone #: Relationship: CONTACT AUTHORIZATION * I authorize Advancing Access to leave a detailed message, including the name of my prescription, if I am unavailable when they call. Yes No I authorize Advancing Access to send me correspondence via U.S. mail. This includes, but is not limited to approval/denial letters for the Patient Assistance Program, reminder letters for re-enrollment periods, etc. If I select “No”, I understand that all communication will be via phone. Yes No Continue Loading please wait .... Privacy Policy Terms of Use Contact Advancing Access at 1-800-226-2056 ADVANCING ACCESS, ATRIPLA, BIKTARVY, COMPLERA, DESCOVY, EMTRIVA, GENVOYA, GILEAD, the GILEAD Logo, ODEFSEY, STRIBILD, TRUVADA, TYBOST, VEMLIDY, and VIREAD are trademarks of Gilead Sciences, Inc., or its related companies. ©2019 Gilead Sciences, Inc. All rights reserved. ADMC0475 09/19...