GlaxoSmithKline

GlaxoSmithKline (GSK) offers Together with GSK Oncology and the GSK Patient Assistance Program to patients prescribed a GSK oncology product. Together with GSK Oncology provides patients and healthcare professionals with a variety of access and reimbursement services for all GSK oncology products—all in one place.

For more information, search the GSK product in this Guide, go online, or call 1.844.447.5662, Monday through Friday, 8:00 AM to 8:00 PM EST.

Oncology-related products: Jemperli (dostarlimab-gxly) injection, Ojjaara (momelotinib) capsules, Zejula® (niraparib) capsules.

Patient Assistance Program

GSK Patient Assistance Program

Uninsured patients who meet eligibility requirements may access medication free of charge through this patient assistance program. Medicare patients who meet program requirements may also be eligible for the program.

Patients may be eligible for this program if:

· They are uninsured

· They have Medicare and meet other program requirements

· Live in one of the United States states, the District of Columbia, Puerto Rico (or the U.S. Virgin Islands for certain medicines)

· Meet financial income eligibility criteria (You can check patient eligibility online).

To enroll, apply online or fax the completed medication-specific enrollment form, including selecting the requested services to the number listed on the form.

The GSK Patient Assistance Program will contact the healthcare professional's office—and will conduct a summary-of-benefits call with the patient within two business days.

For more information, call 1.844.447.5662, Monday through Friday, 8:00 AM to 8:00 PM EST.

Insurance Coverage-Related Delay Program

GSK Quick Start and Bridge Program

For patients experiencing a delay in coverage for Zejula at first dispense (Quick Start), or coverage interruptions while already on treatment (Bridge), download and fill out the Zejula enrollment form. Fax the completed form, plus copies of patient’s medical and pharmacy insurance cards, to 1.800.645.9043.

For more information, call 1.844.447.5662, Monday through Friday, 8:00 AM to 8:00 PM EST.

Reimbursement Assistance

Together with GSK Oncology

For healthcare professionals—and their patients—Together with GSK Oncology offers:

· Patient-specific benefits investigation

· Prior authorization and appeals support

· Claims assistance.

Together with GSK Oncology can provide practices with assistance for claims submissions, including providing examples of forms and sample letters, outlining payer-specific information.

For more information, call 1.844.447.5662, Monday through Friday, 8:00 AM to 8:00 PM EST.

Co-Pay Card/Out-Of-Pocket Cost Assistance

Together with GSK Oncology Co-Pay Program

Eligible, commercially insured patients could pay as little as $0 up to a total of $26,000 for up to 12 months for their GSK medicine.

Patients may be eligible for this program if:

· They have a commercial medical or prescription insurance plan or are uninsured

· They are a resident of the United States (including D.C., Puerto Rico, and the U.S. Virgin Islands)

· They are 18 years or older

· They are not eligible for or enrolled in a government-funded program.

Patients are not eligible for this program if they are covered by any federal or state prescription insurance program. This includes patients enrolled in Medicare Part B, Medicare Part D, Medicaid, Medigap, Veterans Affairs, Department of Defense programs, or TriCare. This may also include state pharmaceutical assistance programs and other federal or state plans not listed. Patients are also ineligible for this program if they are Medicare eligible and enrolled in an employer-sponsored group waiver health plan or government-subsidized prescription drug benefit program for retirees.

Once the medication-specific application is received, the Together with GSK Oncology Co-pay Program will evaluate the patient for eligibility and communicate eligibility. Final patient eligibility determinations are provided by the Together with GSK Oncology HUB.

For more information, call 1.844.447.5662, Monday through Friday, 8:00AM to 8:00 PM EST.

Oncology-related products: Blenrep (belantamab mafodotin-blmf) for injection, Jemperli (dostarlimab-gxly) injection, Zejula^® (niraparib) capsules

Patient Assistance Program

GSK Patient Assistance Program

Uninsured patients who meet eligibility requirements may access medication free of charge through this patient assistance program. Medicare patients who meet program requirements may also be eligible for the program.

Patients may be eligible for this program if:

• They are uninsured

• They have Medicare and meet other program requirements

• Live in one of the United States states or Puerto Rico (or the U.S. Virgin Islands for certain medicines)

• Meet financial income eligibility criteria (You can check patient eligibility online).

To enroll, apply online or fax the completed medication-specific enrollment form, including selecting the requested services to the number listed on the form.

Together with GSK Oncology will contact the healthcare professional's office by the next business day—and will conduct a summary-of-benefits call with the patient within two business days.

For more information, call 1.844.447.5662, Monday through Friday, 8:00 AM to 8:00 PM EST.

Insurance Coverage-Related Delay Program

GSK Quick Start and Bridge Program

For patients experiencing a delay in coverage for Zejula at first dispense (Quick Start), or coverage interruptions while already on treatment (Bridge), download and fill out the Zejula enrollment form. Fax the completed form, plus copies of patient’s medical and pharmacy insurance cards, to 1.800.645.9043.

For more information, call 1.844.447.5662, Monday through Friday, 8:00 AM to 8:00 PM EST.

Reimbursement Assistance

Together with GSK Oncology

For healthcare professionals—and their patients—Together with GSK Oncology offers:

• Patient-specific benefits investigation

• Prior authorization and appeals support

• Claims assistance.

Together with GSK Oncology can provide practices with assistance for claims submissions, including providing examples of forms and sample letters, outlining payer-specific information.

For more information, call 1.844.447.5662, Monday through Friday, 8:00 AM to 8:00 PM EST.

Co-Pay Card/Out-Of-Pocket Cost Assistance

Together with GSK Oncology Co-Pay Program

Eligible, commercially insured patients could pay as little as $0 up to a total of $26,000 for up to 12 months for their GSK medicine.

Patients may be eligible for this program if:

• They have a commercial medical or prescription insurance plan or are uninsured

• They are a resident of the United States (including D.C., Puerto Rico, and the U.S. Virgin Islands)

• They are 18 years or older

• They are not eligible for or enrolled in a government-funded program.

Patients are not eligible for this program if they are covered by any federal or state prescription insurance program. This includes patients enrolled in Medicare Part B, Medicare Part D, Medicaid, Medigap, Veterans Affairs, Department of Defense programs, or TriCare. This may also include state pharmaceutical assistance programs and other federal or state plans not listed. Patients are also ineligible for this program if they are Medicare eligible and enrolled in an employer-sponsored group waiver health plan or government-subsidized prescription drug benefit program for retirees.

To enroll patients prescribed Zejula, apply online or fax the completed Zejula enrollment form to 1.800.645.9043.

To enroll patients prescribed Blenrep or Jemperli, fax the completed Blenrep or Jemperli enrollment form to the number listed.

Once the medication-specific application is received, the Together with GSK Oncology Co-pay Program will evaluate the patient for eligibility and communicate eligibility. Eligibility in the Together with GSK Oncology Co-pay Program is for one year. Patients must apply for co-pay assistance each year that they wish to participate in the program. Final patient eligibility determinations are provided by the Together with GSK Oncology HUB.

For more information, call 1.844.447.5662, Monday through Friday, 8:00 AM to 8:00 PM EST.