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

GSK Patient Assistance Program Non-Vaccine Application (Spanish)

GSK Patient Assistance Program Attestation of the Necessity of Lamictal Tablets Form

GSK Patient Assistance Program Vaccine Application

GSK Patient Assistance Program Vaccine Application (Spanish)

GSK Patient Assistance Program Vaccine Dose Authorization Request Form
 

Medications
  • Serevent Diskus powder; inhalation (salmeterol xinafoate)
 

Eligibility Requirements   
Insurance Status Must be uninsured
Those with Part D Eligible? Yes, but 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 Good for 12 months
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 July 20, 2020


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 3.
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GSK Reimbursement Resource Center

This program provides patient support assistance

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
  • Serevent Diskus powder; inhalation (salmeterol xinafoate)
 

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 June 09, 2020


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

Patient Access Network Foundation (PAN)

This is a copay assistance program

Provided by: Patient Access Network Foundation


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
  • Serevent Diskus powder; inhalation (salmeterol xinafoate)
 

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 FDA Approved Diagnosis - See Program Website for Details
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 September 28, 2020