Selzentry Patient Assistance Programs

Selzentry: Apply for prescription assistance below

If you are eligible, the programs below can help you afford Selzentry. 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?

ViiV Healthcare Patient Assistance Program

(Program 1 of 2 — Scroll down to see them all )

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
Medications
  • Selzentry (maraviroc)
Eligibility Requirements
  • Insurance Status *Contact program for details.
  • Those with Part D Elibible? Yes
  • Income At or below 500% of FPL
  • Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
  • U.S. Residency Required? Must live in US, DC or Puerto Rico
Application
  • Obtaining Call or download
  • Receiving Faxed, mailed or downloaded from website
  • Returning The completed application can be faxed or mailed back.
  • Doctor's Action Give prescription to patient
  • Applicant's Action Complete section and attach required documents
  • Decision Communicated Patient notified in writing
  • Decision Timeframe Not specified
Medication
  • Amount/Supply Up to 90 day supply
  • Sent To Patient's home, unless otherwise noted
  • Delivery Time Not specified
  • Refill Proces Patient must contact company
  • Limit One year
  • Re-application Those with Medicare Part D reapply after spending $600 on prescription medication each year, all others reapply on anniversary date of when they enrolled
Additional Information
Non Medicare Part D 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 D 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 July 16, 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 2 of 2 — 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
  • Selzentry (maraviroc)
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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