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Program Details

GLAXOSMITHKLINE
Bridges to Access

Lamictal (lamotrigine)
 
CONTACT INFO
Address: PO Box 29038
Phoenix, AZ 85038-9038
Phone: 1-866-728-4368 Provider Phone:
Fax: Website: Bridges to Access
ELIGIBILITY
Eligibility Info:
  • NOTE: Patients should have their advocate call the phone number above for prescreening.
  • Advocates can print applications with patient specific ID codes from the GSK website: http://www.bridgestoaccess.com/enrollment/enrollment-by-mail.html
  • Patient do not need to be US Citizens, but must be a resident of the United States. The Patient must meet financial eligibility criteria based on the federal poverty level, adjusted by household size. Patient must not be eligible for prescription drug benefits through any private or public insurer/payer/program.
  • Income at or below: Single 250 % FPL
      Couple 250 % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
    Medical expenses can be deducted from reported income: No
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Financial
    Prescription
    Physician License #
    Required:
    Both DEA and State
    Prescriber Signature
    Allowed:
    Any Health Care Prescriber
    Application may be
    faxed:
    No
    Eligibility determination
    letter sent:
    None
    MEDICATION
    Receives: Medication
    Shipped To: Not Published
    Not Applicable
    Quantity in Shipment:
    Delivery Time: Not Published
    Re-application Policy: New application every 12 months
    New financial information every 12 months
    Refill Policy: Four additional 90 day refills via mail order after first 60 day supply.
    Other Information:
  • Advocates are healthcare workers involved in the patient’s care.
  • Patients that are enrolled over the phone by an Advocate can get up to a 60-day supply of GlaxoSmithKline medicine immediately at any retail pharmacy for a small copay.
  • Patients who don't need medicine right away can enroll on their own by mailing a completed application with income documentation and a prescription with refills as appropriate for a GlaxoSmithKline medicine to the address on the application. If eligible, the applicant will get a free 90-day supply of GlaxoSmithKline medicine in the mail.
  • Applications can be printed from the GSK website. Each application has a unique patient number which is automatically added from the website. Forms can not be copied.
  • Last Updated: 05/09/2014

     

     

     


    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.



     

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