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Commitment to Access
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Commitment to Access
PO Box 29038
Phoenix, AZ 85038-9038
Phone
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(866) 265-6491
Fax:
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Eligibility
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The patient must have no prescription coverage for the medication and have an income at or below 350% of the Federal Poverty Level. The patient must also be a US resident. GlaxoSmithKline requests that an Advocate be the contact person for the patient throughout the entire process. The advocate can be any healthcare worker involved in the patient' care (i.e., doctor, nurse, social worker, or someone in the healthcare office or facility). In a reversal of an earlier announcement, GlaxoSmithKline reported on May 3rd that it's Patient Assistance Programs will be available to Medicare enrollees that do not sign up for a Part D drug program. However, patients who may be eligible for the Part D Low Income Subsidy will be required to apply for this benefit. GSK will continue to supply these patients with their medicine until a decision has been made as to whether they will receive the subsidy. If you have further questions feel free to contact customer service at 1-888-825-5249. |
| Who Can Apply
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The patient advocate can call for an application or start the application process on line. The application will be faxed out. The completed application can be faxed or mailed back. Notification of acceptance or denial is sent to whomever started the application process.
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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.
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Supply
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A 30-day supply is sent to the doctor's office. |
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Ship To
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Physician's office. |
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Note
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The doctor/doctor's office must contact the company to arrange refills. Every year a new application is needed. |
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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.
| | Leukeran Tablets |
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GlaxoSmithKline Commitment to Access
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PO Box 29038
Phoenix, AZ 85038-9038
Phone
:
866-265-6491
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 350% 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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Up to a 30-day supply |
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Ship To
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Doctor's office |
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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.
| | Leukeran 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.
| | Leukeran Tablets |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form Application Form | (Requires Acrobat Reader) 
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Patient Access Network Foundation (PAN)
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PO Box 221858
Charlotte, NC 28222
Phone
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(866)316-7263
Fax:
(866)316-7263
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Eligibility
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This is a copay assistance program for patients that have health insurance. The patient's insurance must cover the qualifying medication that they are seeking assistance for. Patient with Medicare Part D will be considered on a case by case basis. Patients must be at or below 400-500% of the federal poverty level, must have a medically appropriate diagnosis/condition and must reside and receive treatment in the US. |
| Who Can Apply
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Patients or healthcare providers can complete the application online or by phone. |
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Required
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Patients must call for information or inform their doctor that they are in need. Doctors action will be discussed with the patient and doctor after the request is received. |
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Supply
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Not applicable |
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Ship To
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Patient sent card to be used at pharmacy |
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Note
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*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.
Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.
Note: All new enrollment is now done electronically or over the phone. Contact program for details. |
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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.
| | Leukeran Tablets |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form | | (Requires Acrobat Reader)
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