Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.

Program 1 of 1.  Updated May 15, 2013 Back | Print Page

This program provides brand name medications at no or low cost.

Commitment to Access - Patient Assistance

Provided by:


GlaxoSmithKline
PO Box 29038
Phoenix, AZ 85038-9038


TEL: 866-265-6491


ALT PHONE:
FAX:
Program Website

Languages Spoken: English

Patient assistance
applications


 

Medications

Arranon Injection  (nelarabine)

Eligibility Requirements

APPLICATION

MEDICATION
Insurance Status Must have no prescription coverage, generic coverage only or have spent $600 on medications in current year if in Part D
Those with Part D Eligible? Yes, with proof of spending $600 on prescription drugs in current calendar year
Income At or below 500% of FPL
Diagnosis/Medical Criteria Not required
US Residency Required? Must live in one of the 50 states, the District of Columbia, or Puerto Rico and utilize the US healthcare system
Obtaining Doctor/Doctor's office/Social worker must call for prescreening
Receiving Faxed or mailed to patient, doctor, or patient's rep
Returning Mail
Doctor's Action Complete section, sign, attach prescription
Applicant's Action Complete section, sign, attach proof of income
Decision Communicated Decision made during phone screening
Decision Timeframe Decision made during phone screening
Amount/Supply Up to 30 day supply
Sent To Address of shipment varies by medication
Delivery Time Not specified
Refill Process Doctor's office must contact the company
Limit Not specified
Re-application New application yearly

Additional Information:

Patients Taking Arzerra:  Patients with prescription drug benefits through Medicare Part B or through a commercial plan may be eligible for COMMITMENT TO ACCESS® when they have a copayment that exceeds $2,000.

Program asks an Advocate be the contact person for the patient throughout the entire process. The advocate can be any healthcare worker involved in the patient's care. The application needs a total of 3 signatures; doctor, patient and advocate.
Each application must have a unique patient id number. Information about reimbursement support and Co-Pay Assistance are available at 888-663-4752



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