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      Patient Assistance Program Center

Program Details

GSK Patient Assistance Program

Breo Ellipta (fluticasone furoate and vilanterol inhalation powder)
Address: PO Box 220590
Charlotte, NC 28222-0590
Phone: 1-866-728-4368 Provider Phone:
Fax: 1-855-474-3063 Website: Program Website
Eligibility Info:
  • The patient must live in one of the 50 states, District of Columbia or Puerto Rico
  • Patient must not have prescription drug benefits through any insurer/payer/program.
  • Patients with Medicare Part D Prescription Drug Plan may be eligible. Patient must have spent at least $600 on prescription medicines through Medicare Part D Prescription Drug Plan during this calendar year.
  • 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: Not Published
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    Attachments Required: Financial
    Copy of Medicare Part D prescription drug card, if applicable.
    Physician License #
    Prescriber Signature
    Application may be
    Eligibility determination
    letter sent:
    Receives: Medication
    Shipped To: Either Provider and Patient
    Quantity in Shipment: Up to 90-day supply
    Delivery Time: Not Published
    Re-application Policy: New application every 12 months
    Refill Policy: Patient must contact program
    Other Information:
  • Note: Puerto Rico Residents do not qualify for vaccine products.
  • Last Updated: 04/21/2022




    Application Forms
    & Instructions

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

    Document Non- Vaccine Application

    Document Non-Vaccine Spanish Application


    Print-friendly version

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