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Patient Assistance Information

 
 
 
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