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GlaxoSmithKline Commitment to Access
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PO Box 29038
Phoenix, AZ 85038-9038
Phone
:
866-265-6491
Fax:
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Eligibility
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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
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The patient advocate can call for an application or start the application process on line. |
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Required
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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. |
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Supply
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Up to a 30-day supply |
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Ship To
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Doctor's office |
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Note
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The patient advocate can call for an application or start the application process on line. |
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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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| Arranon Injection |
| Bexxar Injection |
| Hycamtin Injection |
| Leukeran Tablets |
| Myleran Tablets |
| Tabloid Tablet |
| Tykerb |
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GlaxoSmithKline Bridges to Access Program
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PO Box 29038,Phoenix, AZ 85038-9038
Phoenix, AZ 85038-9038
Phone
:
866-728-4368
Fax:
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Eligibility
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The patient must have no prescription coverage for the requested medication and have an income at or below 250% of the Federal Poverty Level. The patient must also be a US resident. |
| Who Can Apply
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The patient advocate can call for an application or start the application process on line. |
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Required
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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. |
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Supply
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Ship To
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Patient's home advocate |
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Note
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The patient advocate can call for an application or start the application process on line. |
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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 Inhalation Powder |
| Advair HFA |
| Agenerase Capsules |
| Agenerase Oral Solution |
| Albenza Tablets |
| Altabax Ointment |
| Amerge Tablets |
| Amoxil Capsules |
| Amoxil Oral Solution |
| Amoxil Powder for Oral Suspension |
| Amoxil Tablets |
| Amoxil Tablets - Chewable |
| Arixtra Injection |
| Augmentin |
| Augmentin ES Tablets |
| Augmentin ES-600 Powder for Oral Suspension |
| Augmentin Oral Solution |
| Augmentin powder for Oral Suspension |
| Augmentin Tablets |
| Augmentin Tablets - chewable |
| Augmentin XR Tablets |
| Avandamet Tablets |
| Avandaryl Tablets |
| Avandia Tablets |
| Avodart Soft Gelatin Capsules |
| Axid (nizatidine) |
| Bactroban Cream |
| Bactroban Ointment |
| Beconase AQ Nasal Spray |
| Bexxar Injection |
| Combivir Tablets |
| Coreg CR Tablets |
| Cutivate |
| Daraprim Tablets |
| Dyazide Capsules |
| Dynacirc CR Tablets |
| Epivir HBV Oral Suspension |
| Epivir Oral Suspension |
| Epivir Tablets |
| Epivir-HBV Oral Solution |
| Epivir-HBV Tablets |
| Epzicom Tablets |
| Flovent Aerosal Spray |
| Flovent Inhaler |
| Flovent Rotadisk |
| Fortaz Injection |
| Imitrex Injection |
| Imitrex Nasal Spray |
| Imitrex Tablets |
| InnoPran XL |
| Lamictal Tablets |
| Lamictal Tablets - Chewable |
| Lanoxicaps Capsules |
| Lanoxin Pediatic Elixer |
| Lanoxin Pediatric elixer |
| Lexiva Tablets |
| Lotronex Tablets |
| Lovaza Capsules |
| Malarone Pediatric Tablets |
| Malarone Tablets |
| Mepron Suspension |
| Parnate Tablets |
| Paxil CR Tablets |
| Paxil Oral Suspension |
| Paxil Tablets |
| Relenza (zanamavir) |
| Requip Tablets |
| Retrovir Capsules |
| Retrovir Syrup |
| Retrovir Tablets |
| Rythmol SR (propafenone HCl) |
| Rythmol SR Capsules |
| Serevent Diskus Powder for Inhalation |
| Timentin |
| Timentin Injection |
| Trizivir Tablets |
| Valtrex Capsules |
| Ventolin HFA Inhaler |
| Veramyst Nasal Spray |
| Vesicare Tablets |
| Wellbutrin SR (bupropion HCL) |
| Wellbutrin SR Tablets |
| Wellbutrin XL Tablets |
| Zantac Efferdose Tablets |
| Zantac Injection |
| Zantac Injection - premixed |
| Zantac Syrup |
| Ziagen Oral Solution |
| Ziagen Tablets |
| Zinacef Injection |
| Zofran Tablets-orally disintergrating |
| Zovirax Capsules |
| Zovirax Suspension |
| Zyban Sr Tablets |
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Commitment to Access
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Commitment to Access
PO Box 29038
Phoenix, AZ 85038-9038
Phone
:
(866) 265-6491
Fax:
|
|
Eligibility
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The patient must have no prescription coverage for the medication and have an income at or below 350% of the Federal Poverty Level. The patient must also be a US resident. GlaxoSmithKline requests that an Advocate be the contact person for the patient throughout the entire process. The advocate can be any healthcare worker involved in the patient' care (i.e., doctor, nurse, social worker, or someone in the healthcare office or facility). In a reversal of an earlier announcement, GlaxoSmithKline reported on May 3rd that it's Patient Assistance Programs will be available to Medicare enrollees that do not sign up for a Part D drug program. However, patients who may be eligible for the Part D Low Income Subsidy will be required to apply for this benefit. GSK will continue to supply these patients with their medicine until a decision has been made as to whether they will receive the subsidy. If you have further questions feel free to contact customer service at 1-888-825-5249. |
| Who Can Apply
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The patient advocate can call for an application or start the application process on line. The application will be faxed out. The completed application can be faxed or mailed back. Notification of acceptance or denial is sent to whomever started the application process.
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Required
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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.
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Supply
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A 30-day supply is sent to the doctor's office. |
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Ship To
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Physician's office. |
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Note
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The doctor/doctor's office must contact the company to arrange refills. Every year a new application is needed. |
| |
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.
|
| Bexxar Injection |
| Hycamtin Injection |
| Leukeran Tablets |
| Myleran Tablets |
| Tabloid Tablet |
| Tykerb |
| Zofran Tablets-orally disintergrating |
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Orange Card
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Orange Card
,
Phone
:
(888) 672-6436
Fax:
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Eligibility
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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.
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| Who Can Apply
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Patient should call for application. |
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Required
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Minimal information is required. |
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Supply
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Ship To
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Note
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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 |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form Application Form |
(Requires Acrobat Reader) 
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