Patient Assistance Program for Medicare Part D enrollees

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About GSK Access

GSK Access is a program sponsored by GlaxoSmithKline that provides GlaxoSmithKline prescription medications at no cost to Medicare Part D Prescription Drug Plan enrollees who meet the eligibility requirements. Eligibility is based on annual household income and proof that the applicant has spent $600 or more for prescription medicines for the year. A completed application along with income documentation and proof of prescription expenses must be mailed to GSK Access for processing. Applicants will be notified if they qualify for the program and, if approved, a pharmacy card will be mailed to the applicant that may be used at any retail pharmacy to pick up GlaxoSmithKline medicines at no cost. Drugs received from this program do not count toward True Out-of-Pocket Spending (TrOOP).

You Can Apply If:

You are enrolled in a Medicare Part D Prescription Drug Plan;

You have spent at least $600 on prescription medications through your
Medicare Part D Prescription Drug Plan this year;

You reside in one of the 50 states or the District of Columbia; and

Your total household annual income is at or below 250% of the Federal
Poverty Level.

Household Size	Annual Household Income*

1	less than $27,581
2	less than $36,851
3	less than $46,121
4	less than $55,391

* Federal Poverty Level amounts in Alaska and Hawaii are higher.

For Oncology and Specialty Pharmacy Products

GSK will offer its existing patient assistance program for oncology and specialty pharmacy medicines, Commitment to Access, to Medicare Part D enrollees who have met the $600 spending threshold. For more information visit CommitmenttoAccess.com.

You are encouraged to report negative side effects of prescription drugs to the FDA.
Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.