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Patient Assistance Information

 
 
 
GlaxoSmithKline Commitment to Access

PO Box 29038
Phoenix, AZ 85038-9038
Phone : 866-265-6491
Fax:
Eligibility
> 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
> The patient advocate can call for an application or start the application process on line.
Required
> 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.
Supply
> Up to a 30-day supply
Ship To
> Doctor's office
Note
> The patient advocate can call for an application or start the application process on line.
 
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.
 
Arranon Injection
Bexxar Injection
Hycamtin Injection
Leukeran Tablets
Myleran Tablets
Tabloid Tablet
Tykerb