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Pharmaceutical Company Glaxo Wellcome Inc.
Program Address Glaxo Wellcome, Inc.
Patient Assistance Program
PO Box 52185
Phoenix, AZ 85072-9711
Toll Free Phone Number 800-722-9294
Fax Number 800-750-9832
Guidelines and Notes This continues to be a complicated and tedious program for advocates who do not have regular consistent contact with patients because of the extent of provider involvement required -- patient advocate must be the liason between the program and the patient. . Even though Glaxo Wellcome merged with Smith Kline Beecham to form Glaxo Smith Kline, they continue to maintain this program under this name for now. Call Monday through Friday 8 am to 8 pm Eastern Time. Program is designed to provide short-term assistance. Patient eligibility depends on patient's household size, income and medical expenses.
Initiating Enrollment Patient advocate must call to register as advocate and to pre-enroll patient. Patient advocate can be any professional willing to serve as liaison with company on behalf of patient on a regular basis. They will send forms that cannot be copied, but advocate must call to register every patient If patient is eligible they will activate card on second page of form so patient can obtain an immediate 30-day supply of medication and then send in form.
Health Provider's Role Doctor completes, signs the form. Gives patient 30 day prescription to take to the pharmacy with card. For subsequent supply,
Patient's Role PATIENT SIGNATURE REQUIRED. Income and financial information also needed on form. Company will request proof of income and copy of picture ID after initial application received. Patient needs to complete and mail form after initial telephone enrollment and doctor's signature and portion are completed.
How Dispensed Patient uses card along with prescription and $5 or $10 co-pay to obtain medication at the pharmacy. Advocate must call before each prescription will be filled.
Amount Dispensed 30 days, then two additional 30 day supplies of the product. Patient must submit additional income and insurance information to be approved for additional 90 day increments.
Refills Company requires additional written documentation of financial status AND a follow up call from designated advocate before they will authorize refills. .
Limit Indefinitely
FDA
Drug Companies

Updated on: 9/30/2002