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Patient Assistance Information

 
 
 
Orange Card

Orange Card
,
Phone : (888) 672-6436
Fax:
Eligibility
> 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.
Who Can Apply
> Patient should call for application.
Required
> Minimal information is required.
Supply
>
Ship To
>
Note
> 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.
 
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 Inhalation Powder
Agenerase Capsules
Amerge Tablets
Amoxil Capsules
Augmentin Oral Solution
Avandemet
Avandia Tablets
Avodart Soft Gelatin Capsules
Bactroban Cream
Beconase AQ Nasal Spray
Combivir Tablets
Daraprim Tablets
Dyazide (Triamterene & Hydrochlorothiazide)
Epivir Tablets
Epivir-HBV Tablets
EskalithCR (Lithium Carbonate)
Flovent Inhaler
Imitrex Tablets
Lamictal Tablets
Lanoxicaps Capsules
Leukeran Tablets
Lexiva Tablets
Malarone Tablets
Mepron Suspension
Myleran Tablets
Parnate Tablets
Paxil (paroxetine HCL)
Relafen (nabumetone)
Relenza (zanamavir)
Requip Tablets
Retrovir Tablets
Serevent Diskus Powder for Inhalation
Stelazine (Trifluoperazine HCl)
Tabloid Tablet
Thorazine (chlorpromazine)
Trizivir Tablets
Valtrex Capsules
Wellbutrin SR (bupropion HCL)
Ziagen Tablets
Zinacef Injection
Zyban Sr Tablets
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader