Apply to GSK Patient Assistance Program
Free GSK medicines for people with limited income who are uninsured or on Medicare Part D. Apply directly with the program; here is what it asks and what happens next.
Who can apply?
| Household | 1 person | 2 people | 3 people | 4 people |
|---|---|---|---|---|
| Yearly income up to | $47,880 | $64,920 | $81,960 | $99,000 |
Maximum annual gross household income: $47,880 for 1, +$17,040 per person (48 states and DC). Alaska, Hawaii and Puerto Rico have separate tables (Puerto Rico $28,800 for 1). Same table on uninsured and Medicare pages. Specialty and oncology products (Benlysta, Nucala, oncology) use separate pages and forms not read.
Uninsured: no prescription drug benefits through any insurer or program, and not receiving government drug coverage (Medicaid, VA, DOD, TRICARE); Puerto Rico residents must not be eligible for Mi Salud or must have been denied. Medicare Part D: must have paid $600 for prescriptions in the current calendar year (copays, deductibles, direct costs; not premiums or family members' costs), shown by the latest Part D Explanation of Benefits. Private insurance: only for specialty and oncology products (per GSK info sheet); otherwise sent to copay programs.
Then what?
Sign
- application with patient certification (authorizes use of information, contact with providers and insurers, and a consumer report to estimate income)
Attach
- signed prescription
- Medicare Part D: all pages of the latest Part D Explanation of Benefits showing $600 spent this year
- Medicare Part D: copy of Part D card
- Medicare Beneficiary Identifier on form
Your prescriber
- writes and signs the prescription; faxed prescriptions valid only if faxed directly from the physician's office with a cover sheet
Send
- Fax 1-855-474-3063
- Mail to The GSK Patient Assistance Program, P.O. Box 220590, Charlotte, NC 28222-0590
Questions: call GSK Patient Assistance Program at 1-866-728-4368. Uninsured: refills for up to 12 months, then reapply. Medicare Part D: through the calendar year; reapply each year after spending $600..
Free. Foundation "does NOT charge any fees to apply for, participate in or deliver medication." EveryCard Rx isn't paid by the program and never sends anything for you. Form , rules checked 2026-11-06 from the program's own pages. Something out of date? Tell us.