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Patient Assistance Programs

 

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Patient Assistance Program (PAP) information is provided to assist Medical Case Managers and Ryan White Program clients in accessing medications available through PAPs.

 

Below are Eligibility Guidelines - to access a specific drug through its PAP - and Enrollment/Application Forms - which is a direct link to the PAP website or enrollment form, if applicable. We suggest you first check the eligibility guidelines and then, if the requirements appear to be met, click on the right-hand column for the PAP enrollment/application form.
Eligibility Guidelines Enrollment/Application Forms
ABILIFY (aripiprazole) ABILIFY (aripiprazole)
ALDARA (imiquimod) No PAP  
APTIVUS (tipranavir) APTIVUS (tipranavir)
APTIVUS (tipranavir) For Medicare APTIVUS (tipranavir) For Medicare
ATRIPLA (tenofovir/emtricitabine/efavire) ATRIPLA (tenofovir/emtricitabine/efavire)
ATRIPLA (tenofovir/emtricitabine/efavire) Co-Pay  
ATRIPLA (tenofovir/emtricitabine/efavire) Welvista ATRIPLA (tenofovir/emtricitabine/efavire) Welvista
BACTRIM DS (tmp/smz ds) Publix (14 days Free)  
BACTRIM DS (tmp/smz ds) Rx Outreach (180 days/$20) BACTRIM DS (tmp/smz ds) Rx Outreach (180 days/$20)
BACTROBAN (mupirocin) BACTROBAN (mupirocin)
BARACLUDE (entecavir) BARACLUDE (entecavir)
BIAXIN (clarithromycin)  
COMBIVIR (zidovudine/lamivudine) COMBIVIR (zidovudine/lamivudine)
COMBIVIR (zidovudine/lamivudine) Savings Card COMBIVIR (zidovudine/lamivudine) Savings Card
COMPAZINE (prochlorperazine) Low Cost Retail  
COMPLERA (rilpivirine /tenofovir/ emtricitabine) COMPLERA (rilpivirine /tenofovir/ emtricitabine)
CRESTOR (rosuvastatin) CRESTOR (rosuvastatin)
CRESTOR (rosuvastatin) For Medicare Part D CRESTOR (rosuvastatin) For Medicare Part D
CRIXIVAN (indinavir) CRIXIVAN (indinavir)
CRIXIVAN (indinavir) Welvista CRIXIVAN (indinavir) Welvista
CYMBALTA (duloxetine) CYMBALTA (duloxetine)
 
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Eligibility Guidelines Enrollment/Application Forms
DAPSONE (diamino-diphenyl sulfone) No PAP
DARAPRIM (pyrimethamine) DARAPRIM (pyrimethamine)
DEPAKOTE (divalproex sodium) DEPAKOTE (divalproex sodium)
DIABETA (glyburide) Low Cost Retail  
DIFLUCAN (fluconazole) Pfizer Connection to Care DIFLUCAN (fluconazole) Pfizer Connection to Care
DIFLUCAN (fluconazole) Pfizer Pfriends DIFLUCAN (fluconazole) Pfizer Pfriends
DROXIA (hydroxia) DROXIA (hydroxia)
EDURANT (rilpivirine) EDURANT (rilpivirine)
EDURANT (rilpivirine) Welvista EDURANT (rilpivirine) Welvista
ELAVIL (amitriptyline) Low Cost Retail  
EMTRIVA (emtricitabine) EMTRIVA (emtricitabine)
EMTRIVA (emtricitabine) Welvista EMTRIVA (emtricitabine) Welvista
EPIVIR (lamivudine) EPIVIR (lamivudine)
EPIVIR (lamivudine) Savings Card EPIVIR (lamivudine) Savings Card
EPIVIR HBV (lamivudine) EPIVIR HBV (lamivudine)
EPOGEN (epoetin alpha) EPOGEN (epoetin alpha)
EPZICOM (abicavir/lamivudine) EPZICOM (abicavir/lamivudine)
EPZICOM (abicavir/lamivudine) Savings Card EPZICOM (abicavir/lamivudine) Savings Card
FLUMADINE (rimantadine) No PAP  
FOLINIC ACID (leucovorin) No PAP  
FUZEON (enfuvirtide)  
 
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Eligibility Guidelines Enrollment/Application Forms
GEODON (ziprasidone hcl) GEODON (ziprasidone hcl)
GLUCOPHAGE (metformin) Low Cost Retail  
GLUCOTROL (glipizide) GLUCOTROL (glipizide)
GLUCOTROL (glipizide) Low Cost Retail  
HEPSERA (adefovir) HEPSERA (adefovir)
HYDREA (hydroxyurea) HYDREA (hydroxyurea)
INTELENCE (etravirine) INTELENCE (etravirine)
INTELENCE (etravirine) Welvista INTELENCE (etravirine) Welvista
INVIRASE (saquinavir)  
ISENTRESS (raltegravir) ISENTRESS (raltegravir)
ISENTRESS (raltegravir) Co-Pay ISENTRESS (raltegravir) Co-Pay
ISENTRESS (raltegravir) Welvista ISENTRESS (raltegravir) Welvista
KALETRA (lopinavir) KALETRA (lopinavir)
KALETRA (lopinavir) Welvista KALETRA (lopinavir) Welvista
KEPPRA (levetiracetam) No PAP  
 
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Eligibility Guidelines Enrollment/Application Forms
LAMICTAL (lamotrigine) LAMICTAL (lamotrigine)
LEVAQUIN (levofloxacin) LEVAQUIN (levofloxacin)
LEXAPRO (escitalopram oxalate) LEXAPRO (escitalopram oxalate)
LEXIVA (fosamprenavir) LEXIVA (fosamprenavir)
LEXIVA (fosamprenavir) Savings Card LEXIVA (fosamprenavir) Savings Card
LIPITOR (atorvastatin) LIPITOR (atorvastatin)
LOMOTIL (diphenoxylate) LOMOTIL (diphenoxylate)
LOPID (gemfibrozil) LOPID (gemfibrozil)
LOPID (gemfibrozil) Savings Card LOPID (gemfibrozil) Savings Card
LYRICA (pregabalin) LYRICA (pregabalin)
MARAVIROC (selzentry) MARAVIROC (selzentry)
MARAVIROC (selzentry) Savings Card MARAVIROC (selzentry) Savings Card
MARINOL (dronabinol) No PAP  
MEGACE (megestrol) Low Cost Retail  
MEPRON (atovaquone) MEPRON (atovaquone)
MONISTAT (miconazole) MONISTAT (miconazole)
MYAMBUTOL (ethambutol) No PAP  
MYCELEX TROCHE (clotrimazole) MYCELEX TROCHE (clotrimazole)
MYCOBUTIN (rifabutin) Pfizer Connection to Care MYCOBUTIN (rifabutin) Pfizer Connection to Care
MYCOBUTIN (rifabutin) Pfizer Pfriends MYCOBUTIN (rifabutin) Pfizer Pfriends
 
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Eligibility Guidelines Enrollment/Application Forms
NEUPOGEN (filgrastim) NEUPOGEN (filgrastim)
NEURONTIN (gabapentin) NEURONTIN (gabapentin)
NIZORAL (ketoconazole) NIZORAL (ketoconazole)
NORVIR (ritonavir) NORVIR (ritonavir)
NORVIR (ritonavir) Welvista NORVIR (ritonavir) Welvista
OXANDRIN (oxandrolone) No PAP  
PAMELOR (nortriptyline) PAMELOR (nortriptyline)
PEGASYS (peginterferon alfa)(2a)  
PEG-INTRON (peginterferon alfa)(2b) PEG-INTRON (peginterferon alfa)(2b)
PRAVACHOL (pravastatin) PRAVACHOL (pravastatin)
PREZISTA (darunavir) PREZISTA (darunavir)
PREZISTA (darunavir) Welvista PREZISTA (darunavir) Welvista
PRILOSEC (omeprazole) PRILOSEC (omeprazole)
PROCRIT (epoetin alfa) PROCRIT (epoetin alfa)
PROZAC (fluoxetine) PROZAC (fluoxetine)
 
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Eligibility Guidelines Enrollment/Application Forms
RELENZA (zanamivir) RELENZA (zanamivir)
REMERON (mirtazapine) REMERON (mirtazapine)
RESCRIPTOR (delavirdine) RESCRIPTOR (delavirdine)
RESCRIPTOR (delavirdine) Savings Card RESCRIPTOR (delavirdine) Savings Card
RETROVIR (zidovudine) RETROVIR (zidovudine)
RETROVIR (zidovudine) Savings Card RETROVIR (zidovudine) Savings Card
REYATAZ (atazanavir) REYATAZ (atazanavir)
REYATAZ (atazanavir) Savings Card REYATAZ (atazanavir) Savings Card
REYATAZ (atazanavir) Co-Pay (Bristol-Meyers) REYATAZ (atazanavir) Co-Pay (Bristol-Meyers)
REYATAZ (atazanavir) Co-Pay (Xubex) REYATAZ (atazanavir) Co-Pay (Xubex)
RIBASPHERE (ribavirin) No PAP  
RISPERDAL (risperidone) RISPERDAL (risperidone)
SPORANOX (itraconazole) SPORANOX (itraconazole)
SULFADIAZINE (sulfadiazine) No PAP  
SUSTIVA (efavirenz) SUSTIVA (efavirenz)
SUSTIVA (efavirenz) Savings Card SUSTIVA (efavirenz) Savings Card
SUSTIVA (efavirenz) Co-Pay (Bristol-Meyers) SUSTIVA (efavirenz) Co-Pay (Bristol-Meyers)
SUSTIVA (efavirenz) Co-Pay (Xubex) SUSTIVA (efavirenz) Co-Pay (Xubex)
SYMMETREL (amantadine) No PAP  
 
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Eligibility Guidelines Enrollment/Application Forms
TAMIFLU (oseltamivir) No PAP  
TERAZOL (terconazole) TERAZOL (terconazole)
TESTOSTERONE - ANDROGEL (testosterone gel) TESTOSTERONE - ANDROGEL (testosterone gel)
TESTOSTERONE - DEPO-TESTOSTERONE (injection) No PAP
TRICOR (Fenofibrate) TRICOR (Fenofibrate)
TRIZIVIR (abicavir/lamivudine/zidovudine) TRIZIVIR (abicavir/lamivudine/zidovudine)
TRIZIVIR (abicavir/lamivudine/zidovudine) Savings Card TRIZIVIR (abicavir/lamivudine/zidovudine) Savings Card
TRUVADA (tenofovir/emtricitabine) TRUVADA (tenofovir/emtricitabine)
TRUVADA (tenofovir/emtricitabine) Co-Pay TRUVADA (tenofovir/emtricitabine) Co-Pay
TRUVADA (tenofovir/emtricitabine) Welvista TRUVADA (tenofovir/emtricitabine) Welvista
VALCYTE (valganciclovir hcl)  
VALTREX (valacyclovir hcl) VALTREX (Valacyclovir HCL)
VIDEX (didanosine)  
VIRACEPT (nelfinavir) VIRACEPT (nelfinavir)
VIRACEPT (nelfinavir) Savings Card VIRACEPT (nelfinavir) Savings Card
VIRAMUNE (nevirapine) VIRAMUNE (nevirapine)
VIRAMUNE (nevirapine) For Medicare VIRAMUNE (nevirapine) For Medicare
VIREAD (tenofovir) VIREAD (tenofovir)
VIREAD (tenofovir) Welvista VIREAD (tenofovir) Welvista
WELLBUTRIN (bupropion) Low Cost Retail  
ZERIT (stavudine)  
ZIAGEN (abacavir) ZIAGEN(abacavir)
ZIAGEN (abacavir) Savings Card ZIAGEN (abacavir) Savings Card
ZITHROMAX (azithromycin) Pfizer Connection to Care ZITHROMAX (azithromycin) Pfizer Connection to Care
ZITHROMAX (azithromycin) Pfizer Pfriends ZITHROMAX (azithromycin) Pfizer Pfriends
ZOLOFT (sertraline) ZOLOFT (sertraline)
ZOVIRAX (acyclovir) ZOVIRAX(acyclovir)
 
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Information is current as of posting date; please notify Susy Martinez of corrections or updates.
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