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 PDP Plan Statement or a statement from your local pharmacy.
• Income. Submit a copy of either your federal income tax return (page one) or the most recent Social Security Benefit Statement for each member of your household.

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:
  GSK Access
  PO Box 52046
  Phoenix, AZ 85072-2046
  Fax Number: 1-866-518-3994
• 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.