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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: 1-855-474-3063 Website: Bridges to Access
ELIGIBILITY
Eligibility Info:
  • Patient do not need to be US Citizen, 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.
  • Patient must not be eligible for Medicaid or Puerto Ricos Government Health Plan Mi Salud.
  • 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:
    Advocate ID Number, if enrolling by phone
    Prescriber Signature
    Allowed:
    Any Health Care Prescriber
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Patient
    MEDICATION
    Receives: Medication
    Shipped To: Either Provider and Patient
    Quantity in Shipment: Up to 90 day supply
    Delivery Time: 0-1 week
    Re-application Policy: New application every 12 months
    New financial information every 12 months
    Refill Policy: Call program to request refills
    Other Information:
  • Patients in need of medication right away may have an Advocate enroll them by phone. If eligible, patient may pick up medicine that day at any retail pharmacy with prescription. In the meantime, Advocate must either fax or mail your application and documentation after the enrollment phone call. Please note that faxed prescriptions are only valid if faxed directly from a physicians office.
  • Last Updated: 09/19/2014

     

     

     


    Application Forms
    & Instructions

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


    DocumentForm (English)



     

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