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 Application

GSK Patient Assistance Program Application (Spanish)

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

 

Medications

  • Shingrix injection (zoster vaccine recombinant)
 

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.

*Puerto Rico Residents do not qualify for vaccine products.

Updated January 03, 2022


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

GSK Patient Assistance Vaccine 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

Program Website

 

Program Applications and Forms

GSK Patient Assistance Vaccine Program Application

GSK Patient Assistance Vaccine Program Application (Spanish)

GSK Patient Assistance Vaccine Program Dose Authorization Request Form

 

Medications

  • Shingrix injection (zoster vaccine recombinant)
 

Eligibility Requirements   

Insurance Status Must be uninsured
Those with Part D Eligible? Yes, but contact program for details
Income Not disclosed
Diagnosis/Medical Criteria Not required
US Residency Required? Must permanently reside in the US and be under the direct care of a US Physician
   

Application

Obtaining Call or download from Programs website
Receiving Faxed, mailed or downloaded from Programs website
Returning Email, fax or mail
Doctor's Action Complete section and sign
Applicant's Action Complete section and sign
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Contact the program for more details.
Sent To Doctor's office or specific site
Delivery Time Not specified
Refill Process Contact program for details.
Limit Contact the program for details
Re-application Contact program for details.
   

Additional Information

FOR HEALTHCARE PROFESSIONALS: GSK Patient Assistance Program (GSK PAP) is no longer able to offer single dose vials for PAP replenishment. A site must accumulate a total of 10 doses within 12 months in order to be eligible for replenishment through the program. Doses approved for all practicing physicians at a unique site address will count towards the accumulation. Furthermore, the total amount of replenishment product received through the GSK PAP will be capped at 200 doses per product per year (20 shipments of 10 vaccines) per unique site.

Updated October 11, 2021