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

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

 

Patient Assistance Applications

GSK Reimbursement Authorization Form

 

Brand Name Medications Covered

 
  • Advair Diskus powder; inhalation
  • Lamictal ODT patient titration kit
  • Advair HFA aerosol; inhalation
  • Lamictal starter kit
  • Anoro Ellipta powder; inhalation
  • Lamictal tablet
  • Arnuity Ellipta powder; inhalation
  • Lamictal tablet; orally disintegrating
  • Avandia tablet
  • Lamictal XR tablet; extended release
  • Beconase AQ spray; nasal
  • Lovaza capsule
  • Breo Ellipta powder; inhalation
  • Malarone tablet
  • Coreg CR
  • Mepron oral suspension
  • Duac gel; topical
  • Relenza powder; inhalation
  • Flovent Diskus powder; inhalation
  • Requip XL tablet; extended release
  • Flovent HFA aerosol; inhalation
  • Rythmol SR capsule; extended release
  • Imitrex spray; nasal
  • Serevent Diskus powder; inhalation
  • Incruse Ellipta powder; inhalation
  • Soriatane capsule
  • Jalyn capsule
  • Tanzeum injection
  • Lamictal CD tablet; chewable dispersible
  • Ventolin HFA
 

Generic Name

 
  • acitretin capsule
  • lamotrigine patient titration kit
  • albiglutide injection
  • lamotrigine starter kit
  • albuterol
  • lamotrigine tablet
  • atovaquone oral suspension
  • lamotrigine tablet; chewable dispersible
  • atovaquone/proguanil tablet
  • lamotrigine tablet; extended release
  • beclomethasone dipropionate monohydrate spray; nasal
  • lamotrigine tablet; orally disintegrating
  • benzoyl peroxide/clindamycin gel; topical
  • omega-3-acid ethyl esters capsule
  • carvedilol
  • propafenone capsule; extended release
  • dutasteride/tamsulosin capsule
  • ropinirole tablet; extended release
  • fluticasone furoate powder; inhalation
  • rosiglitazone maleate tablet
  • fluticasone furoate/vilanterol trifenatate powder; inhalation
  • salmeterol xinafoate powder; inhalation
  • fluticasone propionate aerosol; inhalation
  • sumatriptan spray; nasal
  • fluticasone propionate powder; inhalation
  • umeclidinium bromide powder; inhalation
  • fluticasone propionate/salmeterol xinafoate aerosol; inhalation
  • umeclidinium bromide/vilanterol trifenatate powder; inhalation
  • fluticasone propionate/salmeterol xinafoate powder; inhalation
  • zanamivir powder; inhalation
 

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 November 27, 2017