GSK Patient Assistance Program for Prescription Medicines
Eligibility and Enrollment
If You Have Medicare Part D
This section provides information about the GSK Patient Assistance Program for patients who have Medicare Part D. This program does not constitute health insurance.
To qualify for the GSK Patient Assistance Program, you must:
- Live in one of the 50 states, District of Columbia, Puerto Rico or U.S. Virgin Islands
- Have a Medicare prescription drug plan.
- Not be eligible for Puerto Rico's Government Health Plan Mi Salud, or have applied and been denied
You must also meet certain household income eligibility requirements as outlined below:
| 48 States and DC | |
|---|---|
| Household Size | Maximum Monthly Gross Income |
| 1 | |
| 2 | |
| 3 | |
| 4 | |
| For each additional person, add | |
| Calculate your monthly income limit if you have more than 4 people living in your household, including yourself. | |
|
|
|
| Alaska | |
|---|---|
| Household Size | Maximum Monthly Gross Income |
| 1 | |
| 2 | |
| 3 | |
| 4 | |
| For each additional person, add | |
| Calculate your monthly income limit if you have more than 4 people living in your household, including yourself. | |
|
|
|
| Hawaii | |
|---|---|
| Household Size | Maximum Monthly Gross Income |
| 1 | |
| 2 | |
| 3 | |
| 4 | |
| For each additional person, add | |
| Calculate your monthly income limit if you have more than 4 people living in your household, including yourself. | |
|
|
|
| Puerto Rico | |
|---|---|
| Household Size | Maximum Monthly Gross Income |
| 1 | |
| 2 | |
| 3 | |
| 4 | |
| For each additional person, add | |
| Calculate your monthly income limit if you have more than 4 people living in your household, including yourself. | |
|
|
|
You can enroll yourself in the GSK Patient Assistance Program. Here's how it works:
- Complete the Application
- Complete, print, and sign the GSK Patient Assistance Program enrollment application. You can call 1-866-728-4368 to request an application by mail, or download a program application here:
- Include all pages of your most recent Medicare Part D prescription drug plan statement (Explanation of Benefits - EOB) indicating you have paid a total of $600 for prescriptions in the current calendar year. If your statement is not available, please call the GSK Patient Assistance Program for help to identify other sources of proof at 1-866-728-4368. NOTE: The $600 expenditure can be copays, deductibles and direct costs for any prescription medication. The prescription expenses must not include monthly premiums or expenses of family members.
- For help completing the application, call the GSK Patient Assistance Program at 1-866-728-4368.
- Submit Your Paperwork to the GSK Patient Assistance Program
- Fax or mail your completed and signed application, a copy of your Medicare Part D Prescription Plan ID Card (do not send the original card), all pages of your most recent Medicare Part D prescription drug plan statement (Explanation of Benefits - EOB) indicating you have paid a total of $600 for prescriptions in the current calendar year, and prescription(s) for your GSK medicines to:
The GSK Patient Assistance Program P.O. Box 220590
Charlotte, NC 28222-0590
Fax Number: 1-855-474-3063
(Faxed prescriptions are only valid if they are faxed directly from a physician's office.) - Once your application is received and processed, you will receive a letter that lets you know whether or not you have been enrolled in the GSK Patient Assistance Program.
- A supply of up to 90-days of your GSK medicine(s) will automatically be shipped to the address provided on your application. (Some drugs are only available at a retail pharmacy. You will be notified if your prescription is only available at a retail pharmacy.)
- Fax or mail your completed and signed application, a copy of your Medicare Part D Prescription Plan ID Card (do not send the original card), all pages of your most recent Medicare Part D prescription drug plan statement (Explanation of Benefits - EOB) indicating you have paid a total of $600 for prescriptions in the current calendar year, and prescription(s) for your GSK medicines to:
Refills
- Refills are sent at no cost for the remainder of the calendar year.
- Refills can be ordered here or by calling 1-866-728-4368. Each refill must be requested at least 3 weeks before your existing supply of medicine is completed.
- The prescription number is required each time a refill is requested. The prescription number can be found on the packing slip that comes with each shipment.
Renewing a Prescription
- A physician's office may fax the prescription to 1-855-474-3063.
- Faxed prescriptions are only valid if faxed directly from a physician's office.
- Applicant's name and date of birth must be on each faxed page.
The Re-Enrollment Process
Patients with Medicare Part D need to re-apply to the GSK Patient Assistance Program each calendar year after they have spent at least $600 on prescription medicines through their Medicare Part D Prescription Drug Plan.
- Fax or mail your completed enrollment form and documents to the GSK Patient Assistance Program. Faxed prescriptions are only valid if faxed directly from a physician's office. Applicant's name and date of birth must be on each faxed page.
- If you are eligible for continued assistance through the GSK Patient Assistance Program, your first refill will automatically be sent to the address provided on the application.
