| AIDS Treatment Data Network
611 Broadway, Suite 613, New York, NY, 10012 • www.atdn.org • Tel: (212) 260-8868 • (NYS) 800-734-7104
GlaxoSmithKline
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| Contact | 1-866-PATIENT (1-866-728-4368) http://bridgestoaccess.gsk.com |
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| Program Eligibility | The patient must meet the following criteria to qualify:
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| Enrollment Process |
Pre-Enrollment Enrollment forms are available on the above website or by phone or fax. An Advocate (Physician, nurse, case worker, or someone in the doctor's office) must apply on the patient's behalf. The Patient and the doctor must both complete the enrollment form, including all required signatures, and call Bridges to Access (1-866-PATIENT) to enroll. Enrollment Patient eligibility is determined during the initial phone call. The identification number on the enrollment form is activated if the Patient is eligible. If approved during the phone call, the Patient can take the coupon with a prescription to any retail pharmacy to receive up to a 60-day supply of the prescribed medicine for a $5 co-pay per drug per fill. The enrollment form and appropriate documentation and a prescription must be mailed to the program within 20 days of the enrollment phone call to ensure the Patient receives refills, if needed, by mail order in a timely manner. Post-Enrollment After the enrollment form and necessary documentation are processed, the Patient can be authorized for up to two additional 90-day supplies of medicine that the Advocate will receive by mail. If the Patient remains active in the program, approximately two weeks before the first 90-day medicine supply is finished, the Advocate must call the toll-free number (1-866-PATIENT) to request the next 90-day shipment of medicine to be sent. |
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| Re-Application | The enrollment is good for six months and can be extended to 12 months if needed. At the end of the first six months, the Advocate will receive a form to reauthorize for the second six-month period. |
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| Comments | The application process can take some time before the patient can get the drug, healthcare providers should apply well in advanced of the time when the patient needs the drug. This program is to be used strictly as the "last resort". |
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