| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 1 of 3. Scroll down to see them all. |
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GSK Patient Assistance ProgramThis program provides medication at no cost. |
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Provided by: GlaxoSmithKline |
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PO Box 220590 TEL: 866-728-4368FAX: 855-474-3063 |
Languages Spoken:
English, Others By Translation Service |
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Program Applications and Forms |
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GSK Patient Assistance Program Non-Vaccine Application |
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GSK Patient Assistance Program Non-Vaccine Application (Spanish) |
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GSK Patient Assistance Program Attestation of the Necessity of Lamictal Tablets Form |
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GSK Patient Assistance Program Vaccine Application |
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GSK Patient Assistance Program Vaccine Application (Spanish) |
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GSK Patient Assistance Program Vaccine Dose Authorization Request Form |
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Medications |
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Eligibility Requirements |
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| 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 |
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| 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 |
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| 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 |
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| 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. |
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| Updated December 31, 2020 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 2 of 3. Scroll down to see them all. |
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GSK Reimbursement Resource CenterThis program provides patient support assistance |
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Provided by: GlaxoSmithKline |
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PO Box 221425 TEL: 800-745-2967FAX: 866-216-5292 |
Languages Spoken:
English, Others By Translation Service |
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Program Applications and Forms |
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GSK Reimbursement Authorization Form |
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Medications |
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Eligibility Requirements |
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| 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 |
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| 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 |
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| 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 |
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| 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. |
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| Updated December 31, 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 |
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Provided by: Patient Access Network Foundation |
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TEL: 866-316-7263FAX: 866-316-7261 |
Languages Spoken:
English, Spanish, Others By Translation Service |
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Program Applications and Forms |
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Patient Access Network Foundation (PAN) Application: Contact program |
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Medications |
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Eligibility Requirements |
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| 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 |
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| 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 |
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| 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 |
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| *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. |
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| Updated January 25, 2021 | |||
