GSK Co-Pay Assistance Program is a patient assistance program sponsored by GlaxoSmithKline that helps eligible patients pay insurance copayments for certain GSK medicines. Eligibility is based on household income and insurance status. To apply, fax a completed application along with income documentation to 1.866.272.9439. Applicants will be notified if they qualify for the Program. If approved, the patient will be responsible for paying the approved co-pay amount for each fill of the qualifying GSK medicine. The applicant’s Program co-pay ranges from $25 to $300, depending on the applicant’s household income. Applicants with copayments or coinsurance that exceed 50% will be responsible for any remaining costs not covered by their insurance plan or the Program. Applicants must re-apply annually. Additional information about eligibility requirements and how to complete this form can be obtained by clicking the link or by calling 1.888.ONE.GSKCARES (1.888.663.4752).
Applicants who are eligible for federal or state healthcare programs including Medicare and Medicaid or any similar state or federal program including a state pharmaceutical assistance program or residents of Massachusetts are not eligible for the GSK Co-Pay Assistance Program.