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Patient Assistance Information

 
8 Programs Sponsored By GlaxoSmithKline (External Link)
 
 
Bridges to Access

PO Box 29038
Phoenix, AZ 85038
Phone : (866)728-4368
Fax: (855)474-3063
Eligibility
> This program is intended for patients that have no prescription coverage. Medicare Part D patients are not eligible for this program. Income must be at or below 250% of FPL. Must live in one of the 50 states, the District of Columbia, or Puerto Rico and utilize the US healthcare system.
Who Can Apply
> Call to have application faxed or mailed or download from Programs website. Return application via Fax or Mail. (Note: faxed prescriptions are only valid if faxed directly from a prescriber's office. Submit COPIES of Proof of Household income documents. Do not mail original income or tax documents. Documents submitted can not be returned.) Patient notified in writing of decision within 2-3 days.
Required
> Diagnosis/Medical Criteria not required. Doctor must fax in prescription. Patient must complete application, sign and attach copy of income.
Supply
> Up to 90 day supply. Patient must contact company for refills. Refill limit not specified. New application must completed yearly.
Ship To
> Ship to Patient's home, doctor's office, or the advocate's facility.
Note
> Patients may apply on their own or with the help of an advocate. Fax or mail enrollment documents to the program with patient name and date of birth on each page (faxed prescriptions are only valid if faxed directly from a prescriber's office). Eligible patients may receive 90 day supply of medicine to their home within 7 days of faxed enrollment (mailed enrollments may take longer to receive medicine). If enrollment documents are submitted by mail, submit ONLY COPIES of Proof of Household Income documents. Do not mail original income or tax documents. Documents submitted cannot be returned. Please visit www.BridgesToAccess.com for more information. This program does not constitute health insurance.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Advair Diskus powder; inhalation
Advair HFA aerosol; inhalation
Anoro Ellipta powder; inhalation
Arnuity Ellipta powder; inhalation
Avandia tablet
Avodart capsule; softgel
Bactroban
Bactroban cream; topical
Beconase AQ spray; nasal
Breo Ellipta powder; inhalation
Coreg CR capsule; extended release
Duac gel; topical
Epivir-HBV Oral Solution
Epivir-HBV tablet
Fabior aerosol; foam
Flovent Diskus powder; inhalation
Flovent HFA aerosol; inhalation
Imitrex spray; nasal
Incruse Ellipta powder; inhalation
Jalyn capsule
Lamictal CD tablet; chewable dispersible
Lamictal starter kit
Lamictal tablet
Lamictal tablet; orally disintegrating
Lamictal XR patient titration kit
Lamictal XR tablet; extended release
Lovaza capsule
Malarone tablet
Mepron oral suspension
Potiga tablet
Relenza powder; inhalation
Requip XL tablet; extended release
Rythmol SR capsule; extended release
Serevent Diskus powder; inhalation
Soriatane capsule
Tanzeum injection
Ventolin HFA
Veramyst spray; nasal
 
 
 
GSK Access

PO Box 52046
Phoenix, AZ 85072
Phone : (866)518-4357
Fax: (866)518-3994
Eligibility
> This program is intended for Medicare PartD patients only. Income must be at or below 250% of FPL. Must live in one of the 50 states, the District of Columbia, or Puerto Rico and utilize the US healthcare system.
Who Can Apply
> Call to have application faxed, mailed or downloaded from Programs website. Return application via fax or Mail. (Note: faxed prescriptions are only valid if faxed directly from a prescriber's office. Submit COPIES of Proof of Household income documents. Do not mail original income or tax documents. Documents submitted can not be returned. Patient notified in writing within 2-3 days.
Required
> Diagnosis/Medical Criteria not specified. Doctor must give patient prescription. Patient must complete application, sign and attach required documents.
Supply
> Up to 90 day supply. Patient must contact company for refills. Refill limit not specified. New application must completed yearly.
Ship To
> Ship to Patient's home.
Note
> If enrollment documents are submitted by mail, submit ONLY COPIES of Proof of Household Income documents. Do not mail original income or tax documents. Documents submitted cannot be returned. This program does not constitute health insurance.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Advair Diskus powder; inhalation
Advair HFA aerosol; inhalation
Anoro Ellipta powder; inhalation
Arnuity Ellipta powder; inhalation
Avandia tablet
Avodart capsule; softgel
Bactroban
Bactroban cream; topical
Beconase AQ spray; nasal
Breo Ellipta powder; inhalation
Coreg CR capsule; extended release
Duac gel; topical
Epivir-HBV Oral Solution
Epivir-HBV tablet
Fabior aerosol; foam
Flovent Diskus powder; inhalation
Flovent HFA aerosol; inhalation
Imitrex spray; nasal
Incruse Ellipta powder; inhalation
Jalyn capsule
Lamictal CD tablet; chewable dispersible
Lamictal ODT patient titration kit
Lamictal starter kit
Lamictal tablet
Lamictal tablet; orally disintegrating
Lamictal XR patient titration kit
Lamictal XR tablet; extended release
Lovaza capsule
Malarone tablet
Mepron oral suspension
Potiga tablet
Relenza powder; inhalation
Requip XL tablet; extended release
Rythmol SR capsule; extended release
Serevent Diskus powder; inhalation
Soriatane capsule
Tanzeum injection
Ventolin HFA
Veramyst spray; nasal
 
 
 
GSK Vaccines Access Program


,
Phone : (877)822-2911
Fax: (877)822-1555
Eligibility
> Must have no health insurance for vaccine. Medicare Part D patients are not eligible for this program. Income must be at or below 250% of FPL. Must live in US or DC
Who Can Apply
> Call to have application faxed or mailed. Application must be returned via fax from Doctor's office. Health care provider notified via fax of decision usually the same day.
Required
> Diagnosis/Medical Criteria requires Patient to be 19yr old or older. Doctor must register with program, complete sections, obtain patients completed application with income documentation. Patient must provide prescriber signed application and income documentation.
Supply
> Amount/supply varies. Doctor/Doctor's office must complete replacement form for refills. Refill limit not specified. New application, new documentation to be completed yearly.
Ship To
> Ship to Doctor's office.
Note
> For the Cervarix vaccine, the patient must be female between 19-25 years old. This program does not constitute health insurance.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Boostrix vaccine
Cervarix vaccine
Engerix-B vaccine
Havrix vaccine
RabAvert injection
Twinrix vaccine
 
 
 
Benlysta Gateway Patient Assistance Program

PO Box 222173
Charlotte, NC 28222
Phone : (877)423-6597
Fax: (877)850-9901
Eligibility
> Must not have any insurance or be eligible for state or federal funded healthcare. Medicare Part D patients are not eligible for this program. Income must be at or below 500% of FPL. Must live in US, DC or Puerto Rico.
Who Can Apply
> Call to have application faxed, mailed or download from website. Return application via fax or mail. Patient and Doctor are notified of decision within 24-48hrs.
Required
> Diagnosis/Medical Criteria not specified. Doctor must complete and sign application. Patient must complete application, sign and attach a copy of proof of income.
Supply
> Amount/supply varies. Company contacts Doctor to arrange refills. No refill limit. New application must be complete yearly.
Ship To
> Ships to Doctor's office or infusion site within 2 business days.
Note
>
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Benlysta injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Benlysta Gateway Patient Assistance Program
(Requires Acrobat Reader
 
 
Benlysta Gateway Co-Pay Assistance Program

PO Box 222173
Charlotte, NC 28222
Phone : (877)423-6597
Fax: (877)850-9901
Eligibility
> May have private insurance; must not be government funded. Medicare Part D patients are not eligible for this program. Income information not required. Must live in US, DC or Puerto Rico.
Who Can Apply
> Doctor/Doctor's office starts process by filling out enrollment/statement of medical necessity forms that are sent via fax. Return application via fax. Patient and Doctor are notified within 24-48hrs.
Required
> Diagnosis/Medical Criteria not specified. Doctor & patient must complete and sign application.
Supply
> Amount/supply not applicable. Refills are good for 1 year. Refill limit not applicable. New application must be completed yearly.
Ship To
> Shipping location not applicable.
Note
> The BENLYSTA Copay Card will pay 100% of your out-of-pocket costs for BENLYSTA up to a total of $9,000 annually.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Benlysta injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Benlysta Gateway Co-Pay Assistance Program
(Requires Acrobat Reader
 
 
GSK Reimbursement Resource Center

PO Box 221425
Charlotte, NC 28222
Phone : (800)745-2967
Fax: (866)216-5292
Eligibility
> May have insurance. Medicare PartD determined case by case. Income requirements for this program have not been disclosed. Must be a US resident.
Who Can Apply
> Call to have application faxed or download from website. Return application via fax.
Required
> Medically appropriate condition/diagnosis required. Patient must complete and sign application.
Supply
> Amount/supply not specified. Refill process and limit not specified. Re-application process not specified.
Ship To
> Shipping location not specified.
Note
> This program helps patients and healthcare professionals in the U.S. with coverage, reimbursement and coding issues for certain GSK products. Services include verification of benefits, and assistance with prior authorization processes, denied or underpaid claims, coding issues, and alternate funding research.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Advair Diskus powder; inhalation
Advair HFA aerosol; inhalation
Anoro Ellipta powder; inhalation
Avandia tablet
Avodart capsule; softgel
Bactroban
Bactroban cream; topical
Beconase AQ spray; nasal
Breo Ellipta powder; inhalation
Coreg CR capsule; extended release
Duac gel; topical
Fabior aerosol; foam
Flovent Diskus powder; inhalation
Imitrex spray; nasal
Incruse Ellipta powder; inhalation
Jalyn capsule
Lamictal CD tablet; chewable dispersible
Lamictal ODT patient titration kit
Lamictal starter kit
Lamictal tablet
Lamictal tablet; orally disintegrating
Lamictal XR tablet; extended release
Lovaza capsule
Malarone tablet
Mepron oral suspension
Potiga tablet
Relenza powder; inhalation
Requip XL tablet; extended release
Rythmol SR capsule; extended release
Serevent Diskus powder; inhalation
Soriatane capsule
Tanzeum injection
Ventolin HFA
Veramyst spray; nasal
 
 
 
Gateway to Nucala

PO Box 221797
Charlotte, NC 28222
Phone : (844)468-2252
Fax: (844)237-3172
Eligibility
> This program is intended for patients that have insurance. Medicare Part D patients are not eligible for this program. Income requirements vary. Must reside in the US, DC, Puerto Rico or the USVI.
Who Can Apply
> Call to have application faxed or mailed or download. Return application via fax.
Required
> Medically appropriate condition/diagnosis required. Doctor and Patient must complete and sign application.
Supply
> Amount/supply not specified. Refill process and limit not specified. Re-application process not specified.
Ship To
> Shipping location varies. Delivery time varies.
Note
> This program also provides copay assistance.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Nucala
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Gateway to Nucala
(Requires Acrobat Reader
 
 
Tanzeum Free Sharps Container Program


,
Phone : (855)826-9386
Fax:
Eligibility
> Insurance requirements not specified, this includes Medicare PartD. No income requirements. Must reside in the US.
Who Can Apply
> Patient may call or enroll online.
Required
> Diagnosis/Medical Criteria not specified.
Supply
> Amount/Supply: 1 container. Patient must contact company for refill. Refill limit not specified. Re-application process not specified.
Ship To
> Ships to Patient's home.
Note
> Patient enrolls to receive a free sharps container.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Tanzeum disposal container