1. Medication Payment Decision tree: North Dakota
Does the patient have insurance?
YES
Medicaid or Medicare A or B (hospital coverage)
Patient Assistance Program Eligible and can claim AI/AN Exemption
You can apply to Gilead’s Support program (if Harvoni or Epclusa is prescribed)
Fill out one of the following:
1. Online application: iAssist: OR
2. Paper application: fax to Gilead, download form at:
Medications are shipped from Theracom pharmacy
You can apply to AbbVie Patient Assistance Foundation (if Mavyret is prescribed)
Step 1: If you receive a denial letter from the patient’s Insurance then go to step 2. If approved go to step 4.
Step 2: You can appeal and if you receive a second denial letter, you can apply for patient assistance
Step 3: Approved!
Step 4: You can elect to have the medications shipped to a doctor’s office
The Patient assistance program is a paper form. You can download the form at:
Medicaid Expansion
Formulary Preference
PA criteria similar to ND Mediciaid. More info at
You can fill the medications at a specialty pharmacy and ship the medications to the doctor’s office
Medicare Part D (Prescription Coverage)
Formulary Preference (call insurance company)
You can elect to fill the medications at your pharmacy or order medications through CMOP or McKesson NO
Then the patient is Patient Assistance Program Eligible and can claim AI/AN Exemption
2. Fill out a paper application and fax the form to Gilead. You can download the form at:
The medications are shipped from Theracom pharmacy
You can apply to AbbVie Patient Assistance Foundation (if Mavyret is prescribed)*
Fill out the the Patient assistance program form. The form can be downloaded at:
You can elect to have the medications shipped to a doctor’s office
Medication Payment Decision tree: North Dakota
*Please note that this option is still being explored