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GSK Patient Assistance Program for Prescription Medicines

Eligibility and Enrollment

If You Are Uninsured

This section provides information about the GSK Patient Assistance Program for patients who do not have insurance. This program does not constitute health insurance.

To qualify for the GSK Patient Assistance Program, you must:

  • Live in the United States or Puerto Rico
  • Have no prescription drug benefits through any insurer/payer/program
  • Not be currently receiving prescription drug coverage through a government Program (excluding Medicare), which includes Medicaid, VA, DOD or TriCare benefits
  • Not be eligible for Puerto Rico's Government Health Plan Mi Salud or have applied and been denied
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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.
 

Assistance is available in Spanish and many other languages: 1-866-728-4368

La asistencia está disponible en español y muchos otros idiomas: 1-866-728-4368

Enrollment in the GSK Patient Assistance Program for a non-vaccine product

You can enroll yourself in the GSK Patient Assistance Program. Most patients will enroll by fax or mail. If medicine is needed immediately, you can also enroll by phone.

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  • document icon Enroll by Fax or Mail

    Here's how it works:

    1. Complete the Application
      • Complete, print, and sign the GSK Patient Assistance Program enrollment application.
      • For help completing the application, call the GSK Patient Assistance Program at 1-866-728-4368.
    2. Submit Your Paperwork to the GSK Patient Assistance Program
      • Fax or mail your completed and signed application 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.)

    What happens next?

    • 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.)

    Refills

    • Refills are sent at no cost for up to 12 months after your enrollment.
    • 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.

  • mobile-phone-icon Enroll by Phone (only when medicine is needed immediately)

    GSK PAP Must Receive a Signed Application

    Patients who need medicine that same day should ask their Advocate (i.e. someone such as a healthcare worker, social worker, or case worker, who is involved in the delivery of their healthcare) to fax their completed application with all required signatures to the GSK Patient Assistance Program.

    Once this is received and approved, the program will provide the Advocate with the codes needed at the retail pharmacy for an immediate fill.

    1. Complete the Application
    2. Select an Advocate to Enroll You
      • Select someone involved in your healthcare to enroll you. This person may be a health care worker, social worker, case worker, or anyone involved in the delivery of your healthcare. This person is your Advocate.
      • Review the completed application and documents with your Advocate. Please note that faxed prescriptions are only valid if faxed directly from a physician's office.
      • Your Advocate will fax the completed application with all required signatures to the program at 1-855-474-3063.
      • Your Advocate will call 1‑866‑728‑4368 to find out if you are eligible to receive medicine immediately.
      • During the phone call, your Advocate will be told whether or not you qualify for the program.
      • If eligible, you may pick up your medicine that day at any retail pharmacy with your prescription.

    What should I bring to the pharmacy?

    • GSK Patient Assistance Program retail pharmacy processing information, provided by your Advocate upon completion of successful enrollment.
    • Prescription for up to a 30 day supply of medicine, if appropriate.
    • To order subsequent refills, have the prescription number ready and click here or call 1‑866‑728‑4368 at least 3 weeks before your existing supply of medicine is gone.

    Refills

    • Refills are sent at no cost for up to 12 months after your enrollment.
    • Patients requiring prescription assistance past the initial 30-day period of the phone enrollment will receive refills for medicines through mail order when requested. Some medicines are only available at the pharmacy.
    • 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.

  • Re-enrollment icon About Re-enrollment (needed every 12 months)

    Patients need to re-apply to the GSK Patient Assistance Program every 12 months. 

    • A re-enrollment application will be mailed to you or your Advocate when it is time to re-apply. 
    • Fax or mail your completed re-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 still eligible for continued assistance through the GSK Patient Assistance Program, your first refill will automatically be sent to the address provided on the application.
    • To order subsequent refills, have the prescription number ready and click here or call 1-866-728-4368 at least 3 weeks before the patient's existing supply of medicine is gone.
Enrollment icon

Download an Enrollment Form

Updated Application Forms Now Available

You may call 1‑866‑728‑4368 to request an application by mail, or download a program application here:

Find a GSK program for you.

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See access and copay assistance programs for certain products.

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Learn about the GSK Patient Assistance Program for Vaccines.