No Prescription Coverage Medicare Part D Coverage - BenefitsCheckUp

[Pages:4]PO Box 29038 Phoenix, AZ 85038-9038 Phone: 1.866.728.4368 ? Fax: 1.855.474.3063 Monday?Friday, 8am-8pm Eastern Time ?

PO Box 52046 Phoenix, AZ 85072-2046 Phone: 1.866.518.4357 ? Fax: 1.866.518.3994 Monday?Friday, 9am-7pm Eastern Time ? GSK-

GlaxoSmithKline's patient assistance programs provide certain GlaxoSmithKline medicines at no cost to eligible applicants. Eligibility is based on household income and insurance status. Residents of the United States, District of Columbia, and Puerto Rico are eligible to apply. Please be aware, these programs do not constitute health insurance.

No Prescription Coverage

If you do not have prescription drug coverage, you may be eligible for Bridges to Access. If you are found eligible your enrollment will expire after 12 months. For questions

or assistance completing the application, please call 1.866.728.4368.

Medicare Part D Coverage

If you have Medicare Part D, you may be eligible for GSK Access. If you are found eligible your enrollment will expire

on December 31st of the calendar year. For questions or assistance completing the application, please call

1.866.518.4357.

Application Check List:

Complete the entire form. An incomplete application will delay processing.

Fax or mail the following:

Completed and signed application. Proof of income. A copy of page one of your federal income tax form for the most recently filed tax year or

proof of income from all sources, for all household members, for the most recent 30-days. Signed prescription. Signed original prescription(s) for GSK medication(s) written as medically appropriate. NOTE: Faxed prescriptions will only be accepted as valid if faxed directly from a physician's office and

accompanied by a fax cover sheet. Medicare Part D applicants must also send:

? Proof that they have spent $600 out-of-pocket on prescription medications. Documentation includes all pages of the patient's most recent Medicare Part D prescription drug plan statement (Explanation of Benefits ? EOB) indicating the patient has paid a total of $600 for prescriptions in the current calendar year. If the statement is not available, please call GSK Access at 1.866.518.4357 for help to identify other sources of proof. NOTE: The $600 expenditure can be co-pays, deductibles and direct costs for any prescription medication. The prescription expenses must not include monthly premiums or expenses of family members.

? A copy of their Medicare Part D prescription drug card. Please do not send original card(s).

Please keep a copy of the application and all documents for your records. Please print the applicant's name, date

of birth and patient ID (if available) on each page submitted. Do not send original documents as they will not be returned.

Page 1 of 4

PO Box 29038 Phoenix, AZ 85038-9038 Phone: 1.866.728.4368 ? Fax: 1.855.474.3063 Monday?Friday, 8am-8pm Eastern Time ?

PO Box 52046 Phoenix, AZ 85072-2046 Phone: 1.866.518.4357 ? Fax: 1.866.518.3994 Monday?Friday, 9am-7pm Eastern Time ? GSK-

Patient Name: ___________________________ Patient ID: _______________________ DOB: ___________________ SECTION 1: APPLICANT INFORMATION Required Name (First): ____________________________ (Last): _______________________________________ (M.I.): ___________ Mailing Address: __________________________________________________________City: _______________________ State: _____ ZIP Code: __________ Primary Phone Number: (__________) _________ - _________

Number of people, including applicant, who live in the household?

Number of people dependent on household income?

--

Social Security #:

Birth Date: _____ / _____ / _____ Gender: M F

MM

DD

YYYY

Total Gross Monthly Income: _______________________________ or Gross Annual Income: ______________________________

GSK Medication(s) Requested: _______________________________________________________________________________

SECTION 2: PRESCRIPTION COVERAGE Required

1. Is the applicant enrolled in a Medicare Part D prescription drug plan?

YES NO

If not, check no and skip to question #2

If yes, has the applicant spent $600 or more on prescription expenses since January 1st of the

current calendar year?

If yes, please provide the patient's most recent Medicare Part D prescription drug plan statement (EOB)

indicating the patient paid a total of $600 for prescriptions in the current calendar year.

If no, please wait until the applicant has spent $600 or more to apply.

2. Is the applicant eligible for Puerto Rico's Government Healthcare Program, Mi Salud?

YES NO

3. Does the applicant have prescription drug coverage through a Health Insurance Marketplace

YES NO

Plan/Exchange (also known as Affordable Care Act)?

4. Is the applicant eligible for any state or federal (not including Medicare Part D) prescription drug YES NO

coverage plan such as Medicaid?

5. Does the applicant have any private prescription drug coverage (including employer sponsored

YES NO

plans, private group plans, etc.)?

If yes to question 5 please indicate why assistance is needed: _______________________________________________

SECTION 3: SHIPPING ADDRESS Required if different from Mailing Address

Addressee or Business Name:____________________________________________________________________________

Street Address:_______________________________________________________________________________________

City:__________________________________________________________ State:______ ZIP Code:___________________

Specify addressee's relationship to the applicant: Self Advocate (must complete Advocate Information in Section 4) Other (specify relationship) ___________________________________________________________________________

REFILLS ARE NOT AUTOMATICALLY SHIPPED. PLEASE VISIT US ONLINE OR CALL US TO REQUEST YOUR REFILL. W

Page 2 of 4

PO Box 29038 Phoenix, AZ 85038-9038 Phone: 1.866.728.4368 ? Fax: 1.855.474.3063 Monday?Friday, 8am-8pm Eastern Time ?

PO Box 52046 Phoenix, AZ 85072-2046 Phone: 1.866.518.4357 ? Fax: 1.866.518.3994 Monday?Friday, 9am-7pm Eastern Time ? GSK-

Patient Name: ___________________________ Patient ID: _______________________ DOB: ___________________

SECTION 4: ADVOCATE INFORMATION Required if enrolling by phone. Optional if patient is self enrolling.

Medicare Part D patients may not enroll by phone.

Advocate ID Number:_____________________________ Email Address:__________________________________________ Register at or by calling 1.866.728.4368

Facility Name: ______________________ Name (First): ____________________ (Last): ____________________ (M.I.): ____

Street Address:_______________________________________________________________________________________

City:__________________________________________________________ State:______ ZIP Code:___________________

Phone Number: (__________) _________ - _________ Fax Number: (__________) _________ - _________

By my signature, I certify to the best of my knowledge, the information on this application is correct and complete. I have no knowledge of nor do I have any intent to sell, barter or give this product to

any person other than the Applicant for whom it has been prescribed. To the best of my knowledge, the Applicant has no medical/prescription insurance benefits for the indicated pharmaceutical(s),

i_n_cl_u_di_n_g_M_e_d_ic_a_id_o_r_o_th_e_r_p_u_b_lic_p_r_og_r_a_m_s_o_th_e_r_th_a_n_a_s_in_d_i_ca_t_ed_,_a_n_d_th_e_A_p_p_li_ca_n_t_h_a_s _in_su_f_fi_ci_en_t_f_in_a_n_ci_al_r_es_o_u_rc_e_s_to_p_a_y_f_o_r t_h_e_p_re_s_cr_ib_e_d_t_he_r_a_py_.______________________AS_DI_GV_NO_A_CT_AU_TREE

Advocate Signature (Original signature required. Stamped signature not accepted.)

Date

SECTION 5: ALLERGY AND HEALTH INFORMATION Required

DRUG ALLERGIES Required

Do you have any known drug allergies?

YES NO

If yes, list any known drug allergies: ____________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

HEALTH CONDITIONS Required

Do you have any known health conditions?

YES NO

If yes, list any known health conditions: _________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

REQUIRED SIGNATURE ON LAST PAGE

Page 3 of 4

PO Box 29038 Phoenix, AZ 85038-9038 Phone: 1.866.728.4368 ? Fax: 1.855.474.3063 Monday?Friday, 8am-8pm Eastern Time ?

PO Box 52046 Phoenix, AZ 85072-2046 Phone: 1.866.518.4357 ? Fax: 1.866.518.3994 Monday?Friday, 9am-7pm Eastern Time ? GSK-

Patient Name: ___________________________ Patient ID: _______________________ DOB: ___________________

SECTION 6: AUTHORIZED INDIVIDUALS Optional

For the patient: If you would like to give permission to GSK for other individuals (i.e. adult child, parent, friend) to conduct business on your behalf, please print their names here. Please note: These individuals are in addition to a legal guardian or registered advocate who may already be included on this application.

First Name

Last Name

Relationship to Patient

________________________ ________________________________ ______________________________________

________________________ ________________________________ ______________________________________

________________________ ________________________________ ______________________________________

________________________ ________________________________ ______________________________________

If you (the patient) or any of the above listed authorized individuals would like to receive GSK patient assistance alerts, notifications and updates through email, please provide an email address below.

Email Address: __________________________________________________________________________________________________

SECTION 7: APPLICANT AUTHORIZATION TO RELEASE AND DISCLOSE MEDICAL INFORMATION Required

By my signature I authorize GlaxoSmithKline, as well as McKesson Specialty Arizona Inc. (MSAZ) and any other companies that GlaxoSmithKline uses to administer the GlaxoSmithKline Patient Assistance Programs (the "Program(s)") to do the following:

1) Use any information that I provide in my application for the Program(s) for the purpose of helping me receive GSK products under the program or to administer the Program(s);

2) Receive and keep records of all prescriptions for the medications I receive under the Program(s), which will be used to administer the Program(s); 3) Contact my doctor, healthcare provider, or pharmacist about my application for the Program(s), and disclose to them information contained in

my application, in order to help me receive GSK products under the Program(s) and ensure that program guidelines are being met; 4) Request information from my insurer, doctor, healthcare provider, or pharmacist about the prescribed medications I receive or will receive

under the Program(s) and about my medical condition. This information will be used only to determine my eligibility for the Program(s) and to administer the Program(s); 5) Contact my insurer, other potential funding sources, including the Centers for Medicare and Medicaid Services, social workers or patient advocacy organizations on my behalf in order to determine if I am eligible for health insurance coverage or other funds, and disclose to them information contained in my application or information about my prescribed medications and medical condition that has been provided by my physician, healthcare provider, or pharmacist; 6) Disclose any information obtained from the sources listed above to third parties if required by law.

I understand that GlaxoSmithKline does not charge a fee for participation in the Program(s). If I have used a third party who charges a fee for help with my enrollment form or refills of my medicine, this money is not paid to GlaxoSmithKline.

I understand this Authorization to Release and Disclose Medical Information will remain in effect for as long as I participate in the Program(s) and for a period of 3 years after my participation in the Program(s) ends.

I understand my healthcare providers will not condition my medication treatment on my agreement to sign this Authorization to Release and Disclose Medical Information. I also understand that I have the right to revoke this authorization at any time by calling Bridges to Access at 1.866.728.4368, or for Medicare Part D patients call GSK Access at 1.866.518.4357, and mailing a signed written statement of my revocation to the Program(s). Such a revocation would end my eligibility to participate in the Program(s). Revoking this authorization will prohibit disclosures after the date written revocation is received, except to the extent that action has been taken in reliance on my authorization.

I understand that once medical information about me has been disclosed in reliance upon this Authorization, the information may no longer be protected by federal privacy laws and may be further disclosed.

I certify that the product I receive from the Program(s) is for my own use and will not be sold, bartered or given to any other person. I certify that

the information provided in this application is complete and accurate to the best of my knowledge and agree to notify G__la_x_o_S_m__it_h_K_l_in_e__o_f_a_n_y__ch_a_n_g__e_i_n_m__y_i_n_su__ra_n_c_e__e_li_g_ib_i_li_t_y_o_r_f_in_a_n_c_i_a_l_s_ta_t_u_s_._________________________________________S_PIG_AN_TI_AE_TNU_TRE

Patient or Legal Guardian Signature

Date

Relationship (if other than Applicant)

?2015 GSK. All Rights Reserved.

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