2. Include the following documents
A copy of your Medicare Part D Prescription Plan ID Card - DO NOT SEND the original card.
Proof of Prescription Expenses and Income
- $600 in prescription expenses for the calendar year. This can be in the form of your most recent Part D Plan Statement, or a printout from your local pharmacy that includes all of the following:
Note: Expenditures can be for any prescription medication you take.
- Pharmacy name
- Patient name and date of birth
- List of prescriptions with date(s) of purchase
- Amount paid for medications listed
An original signed prescription for your GSK medicine.
- Faxed prescriptions are only valid if they are faxed directly from a physician’s office. Faxed prescriptions received from any other location will not be accepted and will delay medication shipment to the patient.
(Note: Be sure to print the applicant's name and date of birth on each page of documentation submitted.)
3. Submit Your Application and Documentation
- Mail or fax your completed application along with all required documentation to:
PO Box 52046
Phoenix, AZ 85072-2046
Fax Number: 1-866-518-3994
If enrollment documents are submitted by mail, submit copies of Proof of Household Income documents and of your Medicare Part D Prescription Plan ID Card. Do not mail original income or tax documents, or your original Medicare Part D card. Documents submitted cannot be returned.
- Once the completed application is received, it is typically processed within two business days. Notification of acceptance or denial will be sent by mail. If approved, and we have received a valid prescription for you, your first fill of GSK medicine will be shipped to you.