ADVAIR™ DISKUS®
(fluticasone propionate and salmeterol inhalation powder)
For Oral Inhalation Only AGENERASE®
(amprenavir)
Oral Solution AGENERASE®
(amprenavir)
Capsules ALKERAN®
(melphalan hydrochloride)
for Injection ALKERAN®
(melphalan)
Tablets AMERGE®
(naratriptan hydrochloride)
Tablets BECONASE®
(beclomethasone dipropionate)
Nasal Inhaler BECONASE AQ®
(beclomethasone dipropionate)
Nasal Spray CEFTIN®
(cefuroxime axetil tablets)
Tablets CEFTIN®
(cefuroxime axetil powder for oral suspension)
for Oral Suspension COMBIVIR®
(lamivudine/zidovudine)
Tablets DARAPRIM®
(pyrimethamine)
Tablets DEXEDRINE®
(brand of dextroamphetamine sulfate)
Spansule Capsules and Tablets ELLIPSE COMPACT SPACERS EPIVIR®
(lamivudine)
Tablets and Oral Solution EPIVIR-HBV®
(lamivudine)
Tablets and Oral Solution FLOLAN®***
(epoprostenol sodium)
Injection FLONASE®
(fluticasone propionate)
Nasal Spray FLOVENT®
(fluticasone propionate)
Inhalation Aerosol FLOVENT® ROTADISK®
(fluticasone propionate inhalation powder)
For Oral Inhalation Only FORTAZ®
(ceftazidime for injection) IMITREX®
(sumatriptan succinate)
injection IMITREX®
(sumatriptan succinate)
Nasal Spray IMITREX®
(sumatriptan succinate)
Tablets LAMICTAL®
(lamotrigine)
Tablets and Chewable Dispersible Tablets LANOXICAPS®
(digoxin solution in capsules)
50 mcg (0.05 mg) I.D. Imprint A2C (red)
100 mcg (0.1 mg) I.D. Imprint B2C (yellow)
200 mcg (0.2 mg) I.D. Imprint C2C (green) LANOXIN®
(digoxin)
Elixer Pediatric LANOXIN®
(digoxin)
Tablets LEUKERAN®
(chlorambucil)
Tablets MALARONE®
(atovaquone and proguanil hydrochloride)
Tablets MEPRON®
(atovaquone)
Suspension MYLERAN®
(busulfan)
Tablets NAVELBINE®
(vinorelbine tartrate)
Injection PURINETHOL®
(mercaptopurine)
Tablets RELENZA®
(zanamivir for inhalation)
For Oral Inhalation Only RETROVIR®
(zidovudine)
Tablets - Capsules - Syrup SEREVENT®
(salmeterol xinafoate)
Inhalation Aerosol SEREVENT® DISKUS®
(salmeterol xinafoate)
For Oral Inhalation TABLOID® brand
(thioguanine)
Tablets TRIZIVIR®
(abacavir sulfate, lamivudine, and zidovudine)
Tablets VALTREX®
(valacyclovir)
Caplets VENTOLIN®
(albuterol, USP)
Inhalation Aerosol VENTOLIN ROTACAPS®
(albuterol sulfate, USP)
For Inhalation VENTOLIN®
(albuterol sulfate)
Syrup VENTOLIN® HFA
(albuterol sulfate HFA inhalation aerosol) WELLBUTRIN®
(bupropion hydrochloride)
Tablets WELLBUTRIN SR®
(bupropion hydrochloride)
Sustained-Release Tablets ZANTAC®
(ranitidine hydrochloride)
Tablets - EFFERdose Tablets and Granules - Syrup ZANTAC®
(ranitidine hydrochloride)
Injection - Injection Premixed ZIAGEN®
(abacavir sulfate)
Tablets - Oral Solution ZINACEF®
(cefuroxime sodium for injection) ZOFRAN®(ondansetron hydrochloride)
Injection - Injection Premixed ZOFRAN®
(ondansetron hydrochloride)
Tablets - Orally Disintegrating Tablets - Oral Solution ZOVIRAX®
(acyclovir)
Capsules - Tablets - Suspension ZYBAN®
(bupropion hydrochloride)
Sustained Released Tablets The First Step
To enroll in the Glaxo Wellcome Patient Assistance Program, you must select a healthcare advocate who will serve as your representative. A healthcare advocate is someone who is personally involved in the delivery of your healthcare services. This person can be your physician, physician assistant, nurse, pharmacist or anyone else who works in the office or facility where you are treated. Typically you and your advocate are located in the same state. Should your healthcare advocate be located in another state, additional information may be requested of your advocate to determine if the required personal relationship exists. As a patient you cannot serve as your own advocate in the Glaxo Wellcome Patient Assistance Program nor have a family member or personal friend serve as your healthcare advocate. Individuals or entities that charge anything more than a nominal administrative fee for enrolling patients into patient assistance programs may not serve as advocates in the Glaxo Wellcome Patient Assistance Program. The healthcare advocate is responsible for completing the Patient Assistance Program enrollment form and for supplying all supporting documentation that may be requested by the Program during the time the patient remains eligible for the Program. All Program correspondence is sent to the advocate. Should you have any questions about your program status, please have your healthcare advocate call the Glaxo Wellcome Patient Assistance Program at 1-800-722-9294.
Completing the Enrollment Process
For program eligibility consideration, you will need to assist your healthcare advocate in completing Sections 1, 2 and 4 of the enrollment form. In addition to your name, address, and Social Security number, you will be asked for information about your household income and your eligibility for other programs that provide money to pay for medicines. You also must agree to sign the Patient Certification and Consent to Disclosure and Release of Medical Information provisions in Section 5. Your healthcare advocate and the person who prescribes your medication must complete the remaining sections.
Once the enrollment form is complete and all required signatures have been obtained, your healthcare advocate will call the Glaxo Wellcome Patient Assistance Program to determine your eligibility for the program. Enrollment forms mailed to the Glaxo Wellcome Patient Assistance Program prior to calling will not be accepted. Please remember that enrollment in the Glaxo Wellcome Patient Assistance Program can only be made by a healthcare advocate. If you have questions about your status, please have your healthcare advocate call us at 1-800-722-9294.
Getting Your Medicine
If you are eligible for the program, you will receive an initial drug authorization for up to a 30-day supply of medicine. Your advocate will give you a Glaxo Wellcome Patient Assistance Program prescription card that you can take to any retail pharmacy to receive your medication. You will pay only a co-payment of $5 or $10 per prescription, depending on which medicines have been prescribed for you. You must pick up your prescription(s) within 30 days from the time of enrollment approval or your authorization will expire.
Please remember to keep your Glaxo Wellcome Patient Assistance Program prescription card in a safe place and take it with you each time you go to the pharmacy to pick up a prescription. You must contact your healthcare advocate or pharmacy at least 4 to 5 days before your medicine runs out to get a refill. If your prescription changes, provide your pharmacist with a new prescription.
Continued Assistance
Once your advocate returns the top copy of the enrollment form and it is verified for accuracy, you will be eligible to receive two additional 30-day drug authorizations for medicine, a total of 90 days of assistance. If you need continued assistance beyond 90 days, you will be asked to provide household income documentation and certify that your prescription insurance status has not changed. You should contact your healthcare advocate for help in applying for continued assistance. Get In Touch With Us
Your healthcare advocate can get in touch with us for information on enrolling you in the Glaxo Wellcome Patient Assistance Program by:
calling 1-800-722-9294;
visiting us on the worldwide web at www.ipp.gsk.com/pap; or
writing to us at Glaxo Wellcome Patient Assistance Program
P.O. Box 52185
Phoenix, AZ 85072-9711
Patients approved into the Patient Assistance Program should receive their shipment of product within 3-4 weeks. They will not receive an acceptance letter. However, patients and their physicians will receive a denial letter if the patient does not meet the financial guidelines of the Patient Assistance Program.
AstraZeneca Foundation Patient Assistance Program
PO Box 15197 Wilmington, Delaware 19850-5197
800-424-3727
http://www.astrazeneca-us.com/pap/pap_products.asp
acetazolamide (Diamox) Wyeth-Lederle Laboratories
Assitance program for patients who cannot afford medication and have no public or private insurance. Physicians office must call and will receive supply for three months of patient is approved. Processing time is 4-6 weeks.
800-533-3753
1-800 568-9938
carbamazepine (Tegretol) Novartis
Physicians office must call for application. An emergency 30 day supply is sent. There is a small co-pay. Novartis also participates in the drug prescription discount card, which will allow low-income Medicare patients to obtain a discount of 20-40% off retail pharmacy prices.
800-742-2422
800 277-2254
888-272-elan
Carbatrol(R) Shire Richwood, Inc.
Physicians office should call for the application for the indigent patient, who has no private or public insurance. Once approved a three month supply is provided.
1-800-536-7878
908- 203-0657
clonazepam (Klonopin) Roche Pharmaceuticals
Anyone can ask for an application and if approved will get a three months supply. The patient has to re-apply every three months.
800-526-6367
same as general number.
diazepam (Valium) diazapam rectal gel (Diastat) Roche Pharmaceuticals
See under clonazepam.
Xcel Pharmaceuticals
Excel has farmed out its medication assistance program to RXHope (1-800-511-2120 or www.rxhope.com) via physician. Reapplication after three months needs medicaid denial letter.
800-526-6367
866 239-9236
divalproex sodium (Depakote) Abbott
Abbott also participates in the drug prescription discount card, which will allow low-income Medicare patients to obtain a discount of 20-40% off retail pharmacy prices.
800-255-5162
1-800-222-6885 Option 1. Physician calls for application. If patient is approved three months supply is given.
ethosuximide (Zarontin) Pfizer
see under phenytoin
800-223-0432
gabapentin (Neurontin) Pfizer
see under Dilantin.
800-223-0432
lamotrigine (Lamictal) Glaxo Smith Kline
Patients who are not seniors will also receive a prescription card for three months. They can present the card at any pharmacy. There is a $ 5 to $ 10 co-pay for any medication.
Seniors who are eligible for medicare , have an annual income of $ 26,000 single, $ 35,000 per couple and have no private or public insurance for medication are eligible for the orange card , which generates savings of around 30 %.
www.gsk.com
800-722-9294
levetiracetam (Keppra)
Physician’s office calls for patients who are indigent and have no public or private insurance. If application is approved a three months supply is given.
1-800-477-7877
methsuximide (Celontin) Pfizer
See Dilantin
800-223-0432
mephenytoin (Mesantoin) Novartis
800-742-2422
oxcarbazepine (Trileptal) Novartis
see carbamazepine
800-742-2422
phenobarbital Abbott
see valproic acid
800-800-255-5162
phenytoin (Dilantin)Phenytek Pfizer
For non medicare patients the former program applies. Patients or physicians can obtain a n application by calling 908 725-1247 for a three months supply.
Phenytek
www.bertek.com
Physicians can ask for an application at 1-888-823-7835. Bertek follows the Federal Poverty guidelines and gives out supplies for three months.
800-223-0432
Prescription card can be obtained for the following persons: 1. Be enrolled in Medicare. Have no prescription Drug Coverage, Have annual gross income of less than $18,000 per individual;$24,000 per couple. Call the Share Card toll-free number or visit the Pfizer Web
Site:1-800-717-6005 www.pfizerforliving.com
primidone (Mysoline) Xcel
see under Diastat.
866-239-9236
tiagabine hydrochloride (Gabitril) Cephalon
800-782-3656-3-2
The patient can call for an application. Criteria are based on income/debt . If approved three months coupons are delivered . The patient must re-qualify after a year.
topiramate (Topomax) Ortho-McNeil.
Patient and doctor can call. Application must be signed by patient and physician, Proof of income, insurance denial and prescription must be enclosed with the application . If the patient is approved the medication is mailed to the physician;s office. The program is good for one year.
800-255-5162
800-797-7737
www.orthomcneil.com
Vagus Nerve Stimulator Cyberonics
B.J. Wilder therapy access program: Patients with epilepsy, who cannot afford the VNS stimulator, have no insurance or physicians can ask for the application .
800-332-1375
1-888-508-8082
www.cyberonics.com
valproate sodium injection (Depacon) Abbott
see valproic acid.
valproic acid (Depakene) Abbott
800-255-5162
Abilify
Bristol-Myers Squibb Patient Assistance Foundation, Inc.
Contact Information
800-736-0003 (phone)
800-736-1611 (fax)
Physician requests should be directed to:
Bristol-Myers Squibb Patient Assistance Foundation, Inc.
(800) 736-0003 (phone)
http://pap.cowellness.org/programs.cfm?company_id=15
