Help your patients find assistance options that work for them

Patients may be eligible based on the following general eligibility criteria:

• Patient must have a commercial medical or prescription insurance plan.
• Patient is a resident of the US (including the District of Columbia, Puerto Rico, and the US Virgin Islands).
• Patient is not eligible for or enrolled in a government-funded program that provides prescription drug coverage.^*

*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 (VA), Department of Defense (DoD) 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. Patients enrolled in a state or federally funded prescription insurance program may not use this program even if they elect to be processed as an uninsured (cash-paying) patient. Patients enrolled in private indemnity or HMO insurance plans that reimburse them for the entire cost of their prescription drugs are also not eligible.

There are two ways to apply for the HIBSAGO (herein "GSK") Copay Program:

1) Work with their healthcare provider to complete an enrollment form and submit it to the HIBSAGO Copay Program, or
2) apply online at the HIBSAGO Copay Program site.

The Copay Program will evaluate the patient for eligibility and communicate eligibility to the patient and provider. Eligibility in the GSK Copay Program is assessed annually. Patients must qualify for the Copay Program each year that they wish to participate in the Program. Final patient eligibility determinations are provided by the GSK Copay Program.

If the patient is approved, the GSK Copay Program may help with the patient's cost share for HIBSAGO subject to an annual Copay Program Maximum.

The value of the GSK Copay Program is exclusively for the benefit of enrolled patients and is intended to be credited toward patient out-of-pocket responsibilities (e.g., copayments, coinsurance, annual deductibles, and annual out-of-pocket maximums). GSK Copay Program maximums are set at the discretion of GSK. GSK may change or discontinue your Copay Program assistance without notice.

Some prescription drug plans have established programs referred to as “copay maximizer” programs. A copay maximizer program is one in which the amount of the patient’s out-of-pocket costs is adjusted to reflect the availability of support offered by a manufacturer’s copay assistance program. Patients enrolled in copay maximizer programs may be subject to a reduced annual Copay Program maximum at GSK’s sole discretion to ensure that the GSK Copay Program funds are used solely for the benefit of the patient. Annual Copay Program Maximums may vary from patient to patient, depending on the applicable prescription drug plans’ copay maximizer program terms. Patients may call (888) 216-3003 for questions about their available copay program maximum.

• Product Administration Reimbursement: The Copay Program Maximum for administration of the product is $100 per administration and counts towards the annual copay program maximum. Residents of Massachusetts and Rhode Island are not eligible for reimbursement of administrative fees.

Doctor's office visits, labs, and other ancillary services are not included in the Copay Program.

The assistance provided by the GSK Copay Program is offered to, and intended for the sole benefit of, eligible patients and may not be transferred to or utilized for the benefit of third parties, including, without limitation, third-party payers, pharmacy benefit managers, or the agents of either.

The assistance provided by the GSK Copay Program cannot be combined with any other assistance program, free trial, discount, prescription savings card, or other offer.

Patients must have a prescription for the GSK Product in order to apply for the GSK Copay Program. If a patient's prescription drug coverage is provided by a private commercial payer and the commercial payer has opted out of the GSK Copay Program, the patient is not eligible to participate.

The GSK Copay Program is not insurance. GSK reserves the right to rescind, revoke, or amend this offer without notice at any time. Offer good only in the United States (including the District of Columbia, Puerto Rico and the US Virgin Islands). Void where prohibited, taxed, or otherwise restricted by law.

Patients should inform Program representatives of any changes in insurance coverage during the course of enrollment in the GSK Copay Program.