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

Program 1 of 2.
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Updated April 07, 2014
Epivir-HBV

Bridges to Access

Provided by: GlaxoSmithKline

PO Box 29038
Phoenix, AZ 85038-9038

TEL: 866-728-4368


ALT PHONE:
FAX: 1-855-474-3063
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website
 

Patient Assistance Applications

 Bridges to Access Application: Contact program

 

Medications

  • Epivir-HBV  Oral Solution dosage varies (lamivudine)
  • Epivir-HBV  Tablet dosage varies (lamivudine)
 

Eligibility Requirements

Insurance Status Must have no prescription coverage for needed medication
Those with Part D Eligible? No
Income At or below 250% 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
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning 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.)
Doctor's Action Fax in prescription
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified in writing
Decision Timeframe Within 2-3 days
   

Medication

Amount/Supply Up to 90 day supply
Sent To Patientís home, doctorís office, or the advocateís facility
Delivery Time Not specified
Refill Process Patient must contact company
Limit Not specified
Re-application New application yearly
   

Additional Information

Patients may apply on their own or with the help of an advocate. Fax or mail enrollment documents to the program with patient name and date of birth on each page (faxed prescriptions are only valid if faxed directly from a prescriber's office). Eligible patients may receive 90 day supply of medicine to their home within 7 days of faxed enrollment (mailed enrollments may take longer to receive medicine).
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.

Please visit www.BridgesToAccess.com for more information.

This program does not constitute health insurance. Contact program for Spanish application.



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

Program 2 of 2. Updated April 07, 2014
Epivir-HBV

GSK Access

Provided by: GlaxoSmithKline

PO Box 52046
Phoenix, AZ 85072-2046

TEL: 866-518-4357


ALT PHONE:
FAX: 866-518-3994
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website
 

Patient Assistance Applications

 GSK Access Application: Contact program

 

Medications

  • Epivir-HBV  Oral Solution dosage varies (lamivudine)
  • Epivir-HBV  Tablet dosage varies (lamivudine)
 

Eligibility Requirements

Insurance Status May have Medicare Part D
Those with Part D Eligible? Must have Medicare Part D
Income At or below 250% of FPL
Diagnosis/Medical Criteria Not specified
US Residency Required? Must live in one of the 50 states, the District of Columbia, or Puerto Rico and utilize the US healthcare system
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning 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.)
Doctor's Action Give prescription to patient
Applicant's Action Complete section, sign, attach proof of income and any insurance information
Decision Communicated Patient notified in writing
Decision Timeframe Within 2-3 days
   

Medication

Amount/Supply Up to 90 day supply
Sent To Patient's home
Delivery Time Not specified
Refill Process Patient must contact company
Limit Not specified
Re-application New application yearly
   

Additional Information

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.

Contact program for Spanish application.