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GlaxoSmithKline Bridges to Access Program
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PO Box 29038,Phoenix, AZ 85038-9038
Phoenix, AZ 85038-9038
Phone
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866-728-4368
Fax:
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Eligibility
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The patient must have no prescription coverage for the requested medication and have an income at or below 250% of the Federal Poverty Level. The patient must also be a US resident. |
| Who Can Apply
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The patient advocate can call for an application or start the application process on line. |
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Required
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The doctor must fill out a section, sign the application and attach a prescription.The patient must fill out a section, sign the application, and attach proof of income and any denial letters from insurance companies. |
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Supply
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Ship To
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Patient's home advocate |
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Note
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The patient advocate can call for an application or start the application process on line. |
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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.
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| Malarone Tablets |
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Orange Card
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Orange Card
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Phone
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(888) 672-6436
Fax:
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Eligibility
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Seniors age 65 and older and the disabled enrolled in Medicare with annual income below $30,000 single/$40,000 couple (approximately 300% of poverty) and patient must not have public or private insurance coverage for prescription medicines.
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| Who Can Apply
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Patient should call for application. |
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Required
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Minimal information is required. |
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Supply
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Ship To
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Note
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Discounts are 25% off the wholesale list price of GlaxoSmithKline outpatient drugs. Participating pharmacies charge card holders no more than a negotiated price. GlaxoSmithKline expects card holders to realize average savings of 30-40% off retail prices.
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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.
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| Malarone Tablets |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form Application Form |
(Requires Acrobat Reader) 
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