Breo Ellipta Fluticasone furoate and vilanterol trifenatate

Transcription

1 Bre Ellipta Medicatin name Fluticasne furate and vilanterl trifenatate Medicatin classificatin Lng acting beta-agnist and crticsterids Prescriptin assistance prgram Bridges t Access (GlaxSmithKline) Cntact infrmatin and website Phne: (866) Hurs: Mnday - Friday 8:30 a.m. 5:30p.m. ET The GSK Patient Assistance Prgram Eligibility criteria US resident N prescriptin drug benefits thrugh any insurer, payer r prgram Nt eligible fr Medicaid Mnthly husehld grss incme at r belw (48 states and DC) $ fr a single persn $3, fr a family f tw $4, fr a family f three $5, fr a family f fur Fr each additinal persn, add $ Mnthly husehld grss incme at r belw (Alaska residents) $3,137.50fr a single persn $4, fr a family f tw $5, fr a family f three $6, fr a family f fur Fr each additinal persn, add $1, Mnthly husehld grss incme at r belw (Hawaii) $2, fr a single persn $3, fr a family f tw $4, fr a family f three $5, fr a family f fur Fr each additinal persn, add $1, Mnthly husehld grss incme at r belw (Puert Ric ) $2, fr a single persn $ 2,500.00fr a family f tw $ 3,000.00fr a family f three $ 3,500.00fr a family f fur Fr each additinal persn, add $ Cst and enrllment T enrll, use link prvided

2 Select the Get assistance lcated n the tp f the website Chse uninsured assistance and click n enrllment Cmplete all required sectins f the enrllment applicatin that is prvided n the website abve Need t include a valid prescriptin and cpies f prf f husehld incme dcuments Cmpleted and signed applicatin with required dcuments may be faxed r mailed t: The GSK Patient Assistance Prgram Ntificatin f acceptance r denial will be sent by mail, and if yu are apprved with a valid prescriptin then yur first 90-day supply will be shipped t the address prvided n the applicatin If medicatin is needed right away r same day then an advcate (health care wrker, scial wrker, case manager, etc) must call and enrll the patient Refill rder at (866) Patients need t reapply t Bridges t Access every 12 mnths This prgram des nt cnstitute as health insurance Bre Ellipta Medicatin name Medicatin classificatin Prescriptin assistance prgram Fluticasne furate and vilanterl trifenatate Lng acting beta-agnist and crticsterids GSK Access (GlaxSmithKline) Patients with Medicare Part D Cntact infrmatin and website Phne: (866) Hurs: Mnday - Friday 8:30 a.m. 5:30 p.m. ET The GSK Patient Assistance Prgram Eligibility criteria US resident Medicare Part D enrllee wh has spent at least $600 n prescriptin medicatins this calendar year

3 Mnthly husehld grss incme at r belw (48 states and DC) $ fr a single persn $3, fr a family f tw $4, fr a family f three $5, fr a family f fur Fr each additinal persn, add $ Mnthly husehld grss incme at r belw (Alaska residents) $3,137.50fr a single persn $4, fr a family f tw $5, fr a family f three $6, fr a family f fur Fr each additinal persn, add $1, Mnthly husehld grss incme at r belw (Hawaii) $2, fr a single persn $3, fr a family f tw $4, fr a family f three $5, fr a family f fur Fr each additinal persn, add $1, Mnthly husehld grss incme at r belw (Puert Ric ) $2, fr a single persn $ 2,500.00fr a family f tw $ 3,000.00fr a family f three $ 3,500.00fr a family f fur Fr each additinal persn, add $ Cst and enrllment Prescriptin medicatins prvided at n charge t qualified patients T enrll, use link prvided Click n Get assistance lcated n the tp f the website Chse Medicare part D and click n enrllment Cmplete all required sectins f the GSK Access enrllment applicatin that is prvided n the website abve Qualified patients receive prescriptin medicines fr up t 12 mnths at n cst Need t include the fllwing dcuments: A cpy f yur Medicare Part D Prescriptin Plan ID Card Prf f prescriptin expenses and incme An riginal signed prescriptin fr medicine Cmpleted and signed applicatin with required dcuments may be faxed r mailed t: The GSK Patient Assistance Prgram

4 Fax:(855) Ntificatin f acceptance r denial will be sent by mail, and if yu are apprved with a valid prescriptin then yur first 90-day supply will be shipped t the address prvided n the applicatin Refills are sent at n cst thrugh December 31 f the current calendar year. T refill call (866) Medicines received frm this prgram d nt cunt tward true ut-f-pcket spending csts Bre Ellipta Medicatin name Medicatin classificatin Prescriptin assistance prgram Fluticasne furate and vilanterl trifenatate Lng acting beta-agnist and crticsterids Prescriptin Hpe: Natinal advcacy prgram that utilizes direct access t many pharmaceutical cmpany spnsred patient assistance prgrams Cntact infrmatin and website Phne: (877) Fax: (877) Prescriptin Hpe, Inc. P.O.Bx 2700 Westerville, Ohi Eligibility criteria US resident May be uninsured Restrictins d apply (must cmplete enrllment applicatin) The average incme t qualify fr the Prescriptin Hpe pharmacy prgram: Individuals earning arund $30,000 per year Cuples earning arund $50,000 per year Guidelines increase with each additinal member in husehlds earning up t $100,000 per year Cst and enrllment $35 per mnth, per medicatin Cmplete all required sectins f the Prescriptin Hpe enrllment frm that is prvided n the website abve Need t include the fllwing dcuments if applicable:

5 If yu are n Medicare, yu must submit a cpy f yur mst recent Scial Security New Benefit Amunt Statement If yu applied fr Medicaid r have applied fr lw-incme subsidy (LIS), yu must submit a cpy f the determinatin letter Cmpleted and signed applicatin with required dcuments may be cmpleted nline, faxed r mailed t: Prescriptin Hpe, Inc. P.O. Bx 2700 Westerville, Ohi Fax: (877) Prescriptin Hpe des nt guarantee yur apprval fr patient assistance prgrams; it is up t each applicable drug manufacturer t make the eligibility determinatin After enrllment, yu can typically expect t receive 90 days wrth f medicatin delivered t yur hme r dctr s ffice within 4 t 6 weeks Refills will be delivered autmatically befre yur current supply runs ut If Prescriptin Hpe cannt help yu with a medicatin, there will never be a fee fr that medicatin