Arnuity Ellipta Patient Assistance Programs

Arnuity Ellipta: Apply for prescription assistance below

If you are eligible, the programs below can help you afford Arnuity Ellipta. Review the information to see if you qualify. The applications are available in Adobe PDF format and should be mailed directly to the provider of the patient assistance program.

If you have any questions, please call the telephone number for the program (not PharmacyChecker.com) or go to the program website.

Looking for a different medication?

GSK Reimbursement Resource Center

(Program 1 of 3 — Scroll down to see them all )

Provided by: GlaxoSmithKline
PO Box 221425 Charlotte, NC 28222-0265
TEL: 800-745-2967
FAX: 866-216-5292
Languages Spoken:
English, Others By Translation Service
Program Website
Program Applications and Forms
Medications
  • Trelegy Ellipta (fluticasone furoate/umeclidinium/vilanterol)
Eligibility Requirements
  • Insurance Status May have insurance
  • Those with Part D Elibible? Determined case by case
  • Income Not disclosed
  • Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
  • U.S. Residency Required? The patient must also be a US resident.
Application
  • Obtaining Call or download
  • Receiving Faxed or downloaded from website
  • Returning The completed application must be faxed back.
  • Doctor's Action Not specified
  • Applicant's Action Complete section and sign
  • Decision Communicated Not specified
  • Decision Timeframe Not specified
Medication
  • Amount/Supply Not specified
  • Sent To Not specified
  • Delivery Time Not specified
  • Refill Proces Not specified
  • Limit Not specified
  • Re-application Not specified
Additional Information
This program helps patients and healthcare professionals in the U.S. with coverage, reimbursement and coding issues for certain GSK products. Services include verification of benefits, and assistance with prior authorization processes, denied or underpaid claims, coding issues, and alternate funding research.
Updated October 23, 2018

If you, your patient or loved one does not qualify for this program or other prescription savings programs, then please search for prices here.

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GSK Patient Assistance Program

(Program 2 of 3 — Scroll down to see them all )

Provided by: GlaxoSmithKline
PO Box 220590 Charlotte, NC 28222-0590
TEL: 866-728-4368
FAX: 855-474-3063
Languages Spoken:
English, Others By Translation Service
Program Website
Program Applications and Forms
Medications
  • Trelegy Ellipta (fluticasone furoate/umeclidinium/vilanterol)
Eligibility Requirements
  • Insurance Status Must be uninsured
  • Those with Part D Elibible? Yes, but contact program for details
  • Income At or below 250% of FPL
  • Diagnosis/Medical Criteria Not required
  • U.S. Residency Required? The patient must live in one of the 50 states, the District of Columbia, or Puerto Rico* and utilize the US healthcare system
Application
  • Obtaining Call or download from Programs website
  • Receiving Faxed, mailed or downloaded from Programs website
  • Returning Fax or mail (Note: faxed prescriptions are only valid if faxed directly from a prescriber's office)
  • Doctor's Action Fax in prescription
  • Applicant's Action Complete section, sign, attach required documents
  • Decision Communicated Patient notified in writing
  • Decision Timeframe Within 2-3 days
Medication
  • Amount/Supply Up to 90 day supply
  • Sent To Patient's home, doctor's office, or the advocate's facility
  • Delivery Time Not specified
  • Refill Proces Good for 12 months
  • Limit Not specified
  • Re-application New application yearly
Additional Information
Patients may apply on their own or with the help of an advocate. Fax or mail enrollment documents to the program with patient name and date of birth on each page (faxed prescriptions are only valid if faxed directly from a prescriber's office). Eligible patients may receive 90 day supply of medicine to their home within 7 days of faxed enrollment (mailed enrollments may take longer to receive medicine). If enrollment documents are submitted by mail, submit ONLY COPIES of Proof of Household Income documents. Do not mail original income or tax documents. Documents submitted cannot be returned. Prescriber must register for the Vaccines patient assistance program only. Enroll online at GSKPatientAssistanceProgramPortal.com. *Puerto Rico Residents do not qualify for vaccine products.
Updated October 19, 2018

If you, your patient or loved one does not qualify for this program or other prescription savings programs, then please search for prices here.

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Patient Access Network Foundation (PAN)

(Program 3 of 3 — Scroll down to see them all )

Provided by: Patient Access Network Foundation
None
TEL: 866-316-7263
FAX: 866-316-7261
Languages Spoken:
English, Spanish, Others By Translation Service
Program Website
Medications
  • Arnuity Ellipta (fluticasone furoate)
Eligibility Requirements
  • Insurance Status *See Additional Information section below
  • Those with Part D Elibible? Determined case by case
  • Income Between 400-500% of FPL
  • Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
  • U.S. Residency Required? Must reside and receive treatment in US
Application
  • Obtaining Call or complete online
  • Receiving Complete online or by phone
  • Returning Complete online or by phone
  • Doctor's Action Will be discussed with patient and Doctor after request is received
  • Applicant's Action Call for information or inform doctor that he/she is in need
  • Decision Communicated Patient and Doctor notified in writing
  • Decision Timeframe Within 48 hours
Medication
  • Amount/Supply Not applicable
  • Sent To Patient sent card to be used at pharmacy
  • Delivery Time Once approved; shipped same day
  • Refill Proces Patient presents voucher/card to pharmacy for each refill
  • Limit None
  • Re-application New application every 12 months
Additional Information
*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance. Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly. Note: All new enrollment is now done electronically or over the phone. Contact program for details.
Updated July 10, 2018

If you, your patient or loved one does not qualify for this program or other prescription savings programs, then please search for prices here.

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