Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 8.
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GSK Patient Assistance Program

This program provides medication at no cost.

Provided by: GlaxoSmithKline

PO Box 220590
Charlotte, NC 28222-0590

TEL: 866-728-4368


FAX: 855-474-3063
Languages Spoken:

English Others By Translation Service

Program Website

 

Program Applications and Forms

GSK Patient Assistance Program Application

 

Medications

  • albuterol (Ventolin HFA) 
 

Eligibility Requirements   

Insurance Status Contact program for details.
Those with Part D Eligible? Contact program for details.
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 from Programs website
Receiving Faxed, mailed or downloaded from Programs website
Returning Fax or mail (Note: faxed prescriptions are only valid if faxed directly from a prescriber's office)
Doctor's Action Fax in prescription
Applicant's Action Complete section, sign, attach required documents
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, doctor's office, or the advocate's 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.

Prescriber must register for the Vaccines patient assistance program only. Enroll online at GSKPatientAssistanceProgramPortal.com.

*Puerto Rico Residents do not qualify for vaccine products.


Updated November 03, 2017


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 8.
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Merck Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: Merck Patient Assistance, Inc.

PO Box 690
Horsham, PA 19044-9979

TEL: 800-727-5400


Languages Spoken:

English, Spanish

Program Website

 

Program Applications and Forms

Merck Patient Assistance Program Enrollment Form

Merck Patient Assistance Program Enrollment Form (Spanish)

Merck Patient Assistance Program Enrollment Form Instruction Letter (Spanish)

 

Medications

  • albuterol sulfate aerosol; inhalation (Proventil HFA) Aerosol; Inhalation
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Yes
Income At or below 400% of FPL
Diagnosis/Medical Criteria Not specified
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Sent to doctor or patient
Returning Mail original application. Do not fax
Doctor's Action Complete section and sign
Applicant's Action Complete section and sign
Decision Communicated Call for decision
Decision Timeframe Up to 10 business days
   

Medication

Amount/Supply 90 day supply with up to 3 refills, for a total of up to 1 year of medications
Sent To Doctor's office or patient's home
Delivery Time Not specified
Refill Process Patient requests refills via a toll-free number
Limit Not specified
Re-application New application yearly
   

Additional Information

At Merck we realize that sometimes exceptions need to be made based on the patient's individual circumstances. Individuals who do not meet the insurance criteria may still qualify for the Merck Patient Assistance Program if they attest that they have special circumstances of financial hardship, and their income meets the program criteria.

*The Enrollment Form must be mailed. Please do not fax.


Updated May 18, 2017


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 8.
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TEVACares Foundation Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: TEVA Pharmaceuticals

PO Box 52028
Phoenix, AZ 85072

TEL: 877-237-4881


FAX: 877-438-4404
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

TEVACares Foundation Application

 

Medications

  • albuterol (Proair Respiclick) 
  • albuterol aerosol; inhalation (Proair HFA) Aerosol; Inhalation
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage
Those with Part D Eligible? No
Income Based on FPL
Diagnosis/Medical Criteria Not required
US Residency Required? Must be citizen or legal resident
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe 5-7 business days
   

Medication

Amount/Supply Varies
Sent To Doctor's office or patient's home
Delivery Time Within 5-7 business days
Refill Process Reorder form needs to be submitted
Limit Varies per medication
Re-application New application yearly
   

Additional Information

The CephalonCares Foundation Patient Assistance Program for Fentora, Gabitril, Nuvigil and Tev-Tropin and the TEVA Assistance Program are now known as the TEVA Cares Foundation Patient Assistance Program.


Updated September 14, 2017


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 4 of 8.
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Rx Outreach Medications

This program provides medication at low cost. (Most brand names are provided for reference purposes only)

Provided by: Rx Outreach

PO Box 66536
St. Louis, MO 63166-6536

TEL: 888-796-1234


FAX: 800-875-6591
Languages Spoken:

English, Spanish

Program Website

 

Program Applications and Forms

Rx Outreach Application

Rx Outreach Diabetic Supplies Order Form (Prodigy)

Rx Outreach Refills and New Prescription Form

Rx Outreach Medication List

 

Medications

  • albuterol (Proair Respiclick) 
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income At or below 300% of FPL
Diagnosis/Medical Criteria Not required
US Residency Required? Must reside in the US
   

Application

Obtaining Call, download or apply online
Receiving Faxed, mailed or downloaded from website
Returning Fax or E-Prescribe online
Doctor's Action Give prescription to patient
Applicant's Action Complete section and sign
Decision Communicated Medications sent if accepted. If denied patient and doctor notified
Decision Timeframe Usually same day
   

Medication

Amount/Supply Varies
Sent To Doctor's office or patient's home
Delivery Time Not specified
Refill Process Company contacts patient to arrange
Limit Only limited by manufacturer's guidelines
Re-application New application yearly
   

Additional Information

Some medications are available for a fee of $20 for up to a 180 day supply.
Check the Rx Outreach website for the exact price and most current medication list.

Contact Program for Spanish Application(s)/Form(s).


Updated October 03, 2017


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 5 of 8.
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HealthWell Foundation Copay Program

This is a copay assistance program

Provided by: HealthWell Foundation

PO Box 220410
Chantilly, VA 20153-0410

TEL: 800-675-8416


FAX: 800-282-7692
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

HealthWell Foundation Copay Program: Contact program

 

Medications

  • albuterol () 
  • albuterol sulfate (Proventil HFA) 
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Varies
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside in the US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified in writing
Decision Timeframe 3-5 business days
   

Medication

Amount/Supply Not applicable
Sent To Varies
Delivery Time Not specified
Refill Process Good for one year
Limit Not specified
Re-application New application every 12 months
   

Additional Information

This program provides financial assistance to eligible individuals to cover coinsurance, copayments, healthcare premiums and deductibles for certain treatments. Also, for those who are eligible for health insurance, but cannot afford the insurance premium, the foundation may be able to help by paying some or all of the medical portion of insurance premiums. The patient is being treated for a specific disease for which funding is available and has insurance that covers the treatment for this disease.

Call for most recent medications as the list is subject to change.
Updated May 22, 2017


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 6 of 8.
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Patient Access Network Foundation (PAN)

This is a copay assistance program

Provided by: Patient Access Network Foundation

PO Box 221858
Charlotte, NC 28222-1858

TEL: 866-316-7263


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Patient Access Network Foundation (PAN) Application: Contact program

 

Medications

  • albuterol (Proair Respiclick) 
  • albuterol sulfate (Proventil HFA) 
 

Eligibility Requirements   

Insurance Status *See Additional Information section below
Those with Part D Eligible? Determined case by case
Income Between 400-500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Complete online or by phone
Returning Complete online or by phone
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Call for information or inform doctor that he/she is in need
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved; shipped same day
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months
   

Additional Information

*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.

Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.

Note: All new enrollment is now done electronically or over the phone. Contact program for details.


Updated June 29, 2017


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 7 of 8.
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GSK Reimbursement Resource Center

Provided by: GlaxoSmithKline

PO Box 221425
Charlotte, NC 28222-0265

TEL: 800-745-2967


FAX: 866-216-5292
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

GSK Reimbursement Authorization Form

 

Medications

  • albuterol (Ventolin HFA) 
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Determined case by case
Income Not disclosed
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Faxed or downloaded from website
Returning Fax
Doctor's Action Not specified
Applicant's Action Complete section and sign
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Not specified
Sent To Not specified
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Not specified
   

Additional Information

This program helps patients and healthcare professionals in the U.S. with coverage, reimbursement and coding issues for certain GSK products. Services include verification of benefits, and assistance with prior authorization processes, denied or underpaid claims, coding issues, and alternate funding research.


Updated July 10, 2017


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 8 of 8.
 

Merck Connect

For Healthcare Professionals Only

Provided by: Merck & Co., Inc.


TEL: 800-489-5119


Languages Spoken:

English

Program Website

 

Program Applications and Forms

Merck Connect: Contact program

 

Medications

  • albuterol
  • albuterol sulfate aerosol; inhalation
  • albuterol sulfate
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Determined case by case
Income Not disclosed
Diagnosis/Medical Criteria Medically Necessary as determined by a Doctor
US Residency Required? Must be treated by US licensed healthcare provider
   

Application

Obtaining Enroll online
Receiving Not specified
Returning Not specified
Doctor's Action Enroll in the program
Applicant's Action Inform Doctor that he/she is in need
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Up to 30 day supply
Sent To Not specified
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Not specified
   

Additional Information

Resources for HEALTHCARE PROFESSIONALS ONLY.

The Physician must register to access tools and materials for patient support, product sample requests, up-to-date professional resources, and other Merck professional sites.


Updated May 19, 2017