Support Path^® is a program that can help patients get started on Gilead and Asegua treatments.

Support Path Program Navigators can help you understand your insurance coverage and identify potential financial support options based on your circumstances, insurance, and eligibility criteria for programs.

REQUESTED PATIENT SUPPORT PATH OFFERINGS

Please select patient support offerings
CHECK ALL BOXES THAT APPLY

	Benefits Investigation Help research and verify specific insurance coverage for your 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) Eligibility Screening If you lack insurance coverage and meet the program criteria, you may be eligible to receive your medication free of charge.
	Co-Pay Coupon Program Enrollment If you are eligible, a 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 Program, click here and follow the directions in the co-pay section or call Support Path at 1-855-7-MYPATH (1-855-769-7284)

MEDICATION REQUESTED

Product Name*

PATIENT INFORMATION

* Indicates required field.

*Patient First Name:
*Patient Last Name:
*Address:
*Zip Code:
*City:
*State:
Email:
*Preferred Language:
*Phone #:
SSN (last 4 digits):
*DOB:
Gender:	M F
Alternate Contact Name:
Alternate Contact Phone #:
Relationship:

CONTACT AUTHORIZATION

*I authorize Support Path to leave a detailed message, including the name of my prescription, if I am unavailable when they call.	Yes No
I authorize Support Path to send me correspondence via US mail. This includes, but is not limited to, approval/denial letters for the Patient Assistance Program (PAP), reminder letters for re-enrollment periods, etc. If I select “No,” or do not check either box, I understand that all communication will be via phone.	Yes No
I authorize Support Path to provide me with information on my benefits and other communications that contain reference to the Support Path program through the following:	Text Email Phone

*My preferred mobile #

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Please see Important Facts about EPCLUSA, HARVONI, VOSEVI, and VEMLIDY, including Important Warning.

Please see full Prescribing Information for SOVALDI, sofosbuvir/velpatasvir and ledipasvir/sofosbuvir, including Important Warning and Patient Information.

Gilead Privacy Policy | Gilead Terms of Use

Asegua Privacy Policy | Asegua Terms of Use

Contact Support Path at 1-855-769-7284

EPCLUSA, HARVONI, SOVALDI, VOSEVI, VEMLIDY, SUPPORT PATH, the SUPPORT PATH logo, and GILEAD are trademarks of Gilead Sciences, Inc., or its related companies. ASEGUA is a trademark of Asegua Therapeutics LLC. All other trademarks referenced herein are the property of their respective owners.

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