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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.
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| 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 |
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