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
  • Lamictal
  • Advair HFA
  • Lamictal ODT patient titration kit
  • Anoro Ellipta
  • Lamictal starter kit
  • Arnuity Ellipta
  • Lamictal XR
  • Avandia tablet
  • Malarone
  • Beconase AQ spray; nasal
  • Mepron
  • Breo Ellipta powder; inhalation
  • Relenza
  • Coreg CR
  • Requip XL
  • Duac gel; topical
  • Rythmol SR
  • Flovent Diskus
  • Serevent Diskus
  • Flovent HFA
  • Soriatane
  • Imitrex spray; nasal
  • Trelegy Ellipta
  • Incruse Ellipta powder; inhalation
  • Ventolin HFA
  • Jalyn
 

Generic Name

 
  • acitretin
  • fluticasone propionate/salmeterol xinafoate
  • albuterol
  • lamotrigine
  • atovaquone
  • lamotrigine patient titration kit
  • atovaquone/proguanil
  • lamotrigine starter kit
  • beclomethasone dipropionate monohydrate spray; nasal
  • propafenone
  • benzoyl peroxide/clindamycin gel; topical
  • ropinirole
  • carvedilol
  • rosiglitazone maleate tablet
  • dutasteride/tamsulosin
  • salmeterol xinafoate
  • fluticasone furoate
  • sumatriptan spray; nasal
  • fluticasone furoate/umeclidinium/vilanterol
  • umeclidinium bromide powder; inhalation
  • fluticasone furoate/vilanterol trifenatate powder; inhalation
  • umeclidinium bromide/vilanterol trifenatate
  • fluticasone propionate
  • zanamivir
 

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 16, 2018