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Bridges to Access
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PO Box 29038
Phoenix, AZ 85038
Phone
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(866)728-4368
Fax:
(855)474-3063
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Eligibility
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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
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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. |
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Required
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Diagnosis/Medical Criteria not required. Doctor must fax in prescription. Patient must complete application, sign and attach copy of income. |
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Supply
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Up to 90 day supply. Patient must contact company for refills. Refill limit not specified. New application must completed yearly. |
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Ship To
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Ship to Patient's home, doctor's office, or the advocate's facility. |
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Note
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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. |
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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.
| | Bactroban |
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GSK Access
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PO Box 52046
Phoenix, AZ 85072
Phone
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(866)518-4357
Fax:
(866)518-3994
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Eligibility
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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
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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. |
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Required
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Diagnosis/Medical Criteria not specified. Doctor must give patient prescription. Patient must complete application, sign and attach required documents. |
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Supply
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Up to 90 day supply. Patient must contact company for refills. Refill limit not specified. New application must completed yearly. |
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Ship To
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Ship to Patient's home. |
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Note
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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. |
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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.
| | Bactroban |
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GSK Reimbursement Resource Center
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PO Box 221425
Charlotte, NC 28222
Phone
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(800)745-2967
Fax:
(866)216-5292
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Eligibility
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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
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Call to have application faxed or download from website. Return application via fax. |
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Required
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Medically appropriate condition/diagnosis required. Patient must complete and sign application. |
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Supply
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Amount/supply not specified. Refill process and limit not specified. Re-application process not specified. |
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Ship To
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Shipping location not specified. |
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Note
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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. |
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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.
| | Bactroban |
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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.
| | Bactroban |
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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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