|Pharmaceutical Company||Glaxo Wellcome, Inc.|
|Program Address||Patient Assistance Program
P. O. Box 52185
Phoenix, AZ 85072-9711
|Toll Free Phone Number||800-722-9294|
|Alternate Phone Number||800-745-2967|
|Guidelines and Notes||
Some products have a $5 co-pay, some have a $10 co-pay.
Whoever is acting as the patient advocate will have to respond to additional information requests at least every 90 days, so there must be someone who has a continuing relationship with the patient.
After the application is received Glaxo requests proof of patient identification and proof of income in a letter sent to the advocate.
Glaxo also provides advocacy for insurance reimbursement - call 800-423-6869.
|Initiating Enrollment||They will send a form to professionals, but the form can't be copied. Call 9:00am-9:00pm Eastern time Monday-Friday or 9:00am-5:30pm on Saturday.|
|Health Provider's Role||The doctor completes and signs the form. Patient information is phoned in by the patient advocate (nurse, doctor, social worker, etc.) who must be willing to continue to serve as the patient's advocate, calling in information periodically. The doctor writes a prescription for a 90 day supply.|
|Patient's Role||The patient must provide financial information and sign the form.|
|How Dispensed||The patient takes a card to their pharmacy and receives the medication. Once eligibility is determined, the tear-off card on the application is good for a 30 day supply.|
|Amount Dispensed||3 months supply with a co-pay|
|Estimated Response Time||Not specifiied|
|Refills||Patient advocate calls the company to attest the patient is still in need.|