Enrollment

Step 1 of 3

Your personal information is required for security purposes and is used to confirm your identity as a cardholder.

Are you a current resident of the United States, Puerto Rico, or U.S. Territories?

The Gilead Advancing Access® co-pay coupon card is available only to residents of the United States, U.S. Territories, or the Commonwealth of Puerto Rico. For more information about your eligibility for this or other programs, please call .
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Are your prescriptions paid for in part or in full under any state or federally funded program, including but not limited to Medicare or Medicaid, Medigap, VA, DOD, or TRICARE?

The co-pay coupon card is available only to people who currently do not participate in state or federally funded programs. For more information about your eligibility for this or other programs, please call .
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Are you in the Medicare Part D coverage gap (Donut Hole)?

The co-pay coupon card is available only to people who currently do not participate in state or federally funded programs. For more information about your eligibility for this or other programs, please call .
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If you begin receiving prescription benefits from such state, federal, or government-funded program at any time, you will no longer be eligible to use the Gilead Advancing Access® co-pay coupon card.

Do you acknowledge your agreement with this statement?

In order to be eligible for the co-pay coupon card, you must agree with this statement. If you would like to discuss further, please call .
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When you join the Gilead Advancing Access co-pay coupon program, some information will be gathered. Any information provided may be used for internal business purposes by Gilead and its vendors. The information will help us to better understand patient needs. The following will be collected: the date you filled your prescription, the number of pills the pharmacist gave you, how much the program will refund to you, and other prescription information that is learned during this enrollment.

In order to be eligible for the Gilead co-pay coupon card, you must agree with this statement. If you would like to discuss further, please call .