GSK Assistance Prescreen - Patient Demographics

Step 1 of 3

You can find out if you might qualify for one of these programs by answering these few questions.

State you live in:


Your Prescription Drug Benefits: Medicare Part D Prescription Drug Plan Federal or state program including Medicaid Private prescription drug coverage No coverage	Please select your type of coverage.
Have you spent $600 or more on prescriptions this year through Medicare Part D? Yes No	Please specify your out of pocket expenses.
Check all that apply. My prescription plan covers generic drugs ONLY I have a preexisting condition my prescription plan won't cover I am over my prescription plan's coverage limit for the year
Number of people in your household, including yourself, who add to or depend on your income:
Your gross household income: $ from the last 30 days or 12 months	Please specify a time period.