Letairis Patient Assistance Programs

Letairis: Apply for prescription assistance below

If you are eligible, the programs below can help you afford Letairis. Review the information to see if you qualify. The applications are available in Adobe PDF format and should be mailed directly to the provider of the patient assistance program.

If you have any questions, please call the telephone number for the program (not PharmacyChecker.com) or go to the program website.

Looking for a different medication?

Patient Assistance Solutions Program for Letairis

(Program 1 of 3 — Scroll down to see them all )

Provided by: Gilead Sciences, Inc.
PO Box 13185 La Jolla, CA 92039-3185
TEL: 866-664-5327
ALT PHONE: 866-664-5327
FAX: 888-856-7991
Languages Spoken:
English, Others By Translation Service
Program Website
Program Applications and Forms
Medications
  • Letairis (ambrisentan)
Eligibility Requirements
  • Insurance Status Contact program for details.
  • Those with Part D Elibible? Determined case by case
  • Income At or below 500% of FPL
  • Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
  • U.S. Residency Required? The patient must also be residing in the US.
Application
  • Obtaining Call
  • Receiving Faxed or mailed
  • Returning The completed application can be faxed or mailed back.
  • Doctor's Action Complete section and sign
  • Applicant's Action Complete section and sign
  • Decision Communicated Patient and Doctor notified in writing
  • Decision Timeframe 2 business days, once application process is complete
Medication
  • Amount/Supply Contact the program for more details.
  • Sent To Patient's home, unless otherwise noted
  • Delivery Time Contact Program for Details
  • Refill Proces Patient contacts pharmacy
  • Limit Contact the program for details
  • 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 October 17, 2018

If you, your patient or loved one does not qualify for this program or other prescription savings programs, then please search for prices here.

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Good Days Program

(Program 2 of 3 — Scroll down to see them all )

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
Medications
  • Letairis (ambrisentan)
Eligibility Requirements
  • Insurance Status Not specified
  • Those with Part D Elibible? Not specified
  • Income Not disclosed
  • Diagnosis/Medical Criteria Not specified
  • U.S. Residency Required? US residency requirements are not specified.
Application
  • Obtaining Call, download or apply online
  • Receiving Faxed, mailed or downloaded from website
  • Returning The completed application can be faxed, mailed or submitted 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 Proces 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 October 5, 2018

If you, your patient or loved one does not qualify for this program or other prescription savings programs, then please search for prices here.

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Patient Access Network Foundation (PAN)

(Program 3 of 3 — Scroll down to see them all )

Provided by: Patient Access Network Foundation
None
TEL: 866-316-7263
FAX: 866-316-7261
Languages Spoken:
English, Spanish, Others By Translation Service
Program Website
Medications
  • Letairis (ambrisentan)
Eligibility Requirements
  • Insurance Status *See Additional Information section below
  • Those with Part D Elibible? Determined case by case
  • Income Between 400-500% of FPL
  • Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
  • U.S. Residency Required? Must reside and receive treatment in US
Application
  • Obtaining Call or complete online
  • Receiving Complete online or by phone
  • Returning Complete online or by phone
  • Doctor's Action Will be discussed with patient and Doctor after request is received
  • Applicant's Action Call for information or inform doctor that he/she is in need
  • Decision Communicated Patient and Doctor notified in writing
  • Decision Timeframe Within 48 hours
Medication
  • Amount/Supply Not applicable
  • Sent To Patient sent card to be used at pharmacy
  • Delivery Time Once approved; shipped same day
  • Refill Proces 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 July 10, 2018

If you, your patient or loved one does not qualify for this program or other prescription savings programs, then please search for prices here.

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