rxhelp360.org
| Drug Information | |
| Drug | Requip tablet .25mg |
| Generic Equivalent | ropinirole hydrochloride |
| Class | Parkinsons/RLS |
| Topic | Neuro/Mental Health |
| Program Contact Info / Application Submission | |
| Program | Bridges To Access |
| Company | GlaxoSmithKline |
| Form | Download PDF |
| Address | PO Box 29038, Phoenix, AZ 85038-9038 |
| Phone | 866-728-4368 |
| Fax | 800-750-9832 |
| Website | http://www.bridgestoaccess.com/ |
| Program Requirements | |
| Details | Insurance card NOT required Drivers license NOT required Proof of Income required Copy of most recent tax return such as 1040, 1099 NOT required as proof of income Letter from Doctor stating zero income required as proof of income Form 4506T (If taxes were not filed) NOT required as proof of income Most recent bank statements required as proof of income Most recent check/check stub copy required as proof of income Letter from employer required as proof of income Benefits statement for Social Security, Unemployment, Veterans Benefits, Pension/Retirement required as proof of income Award Letter for Alimony/Child Support, Unemployment required as proof of income Notarized statement from patient stating zero income required as proof of income |
| Delivery of Medication | |
| Ship Time | 4-weeks from date of enrollment |
| Delivery Options | Can be delivered directly to the patient Can be delivered directly to the doctor |
| Application Process | |
| New Applications | New applications accepted Patients can apply directly to the program Doctors can apply directly to the program Advocates can apply directly to the program Can NOT apply for a new application via phone Can NOT apply for a new application via fax Can apply for a new application via mail |
| Refills | Refills accepted Patients can apply for refills Doctors can apply for refills Advocates can apply for refills Can apply for refills via phone Can NOT apply for refills via fax Can NOT apply for refills via mail |
| Re-Applications | Re-Applications accepted Patients can apply for Re-Applications Doctors can apply for Re-Applications Advocates can apply for Re-Applications Can NOT Re-Apply via phone Can NOT Re-Apply via fax Can Re-Apply via mail |
| Appeals | Income Appeals NOT accepted Patients can NOT apply for Income Appeals Doctors can NOT apply for Income Appeals Advocates can NOT apply for Income Appeals Hardship Appeals accepted Patients can apply for Hardship Appeals Doctors can apply for Hardship Appeals Advocates can apply for Hardship Appeals Can NOT apply for an appeal via phone Can NOT apply for an appeal via fax Can apply for an appeal via mail |
| Eligibility | |
| Limitations | Patients are eligible if LIS is denied Patients may be eligible with existing prescription coverage on a case by case basis Patients may be eligible if prescription is not covered on a case by case basis Patients may be eligible if prescription coverage has been exhausted on a case by case basis Patients are eligible if they are accepting Medicare Patients are NOT eligible if they are accepting Medicare part D Patients are NOT eligible if the medication is not covered under Medicare Patients are NOT eligible if Medicare coverage has been exhausted |
| Appeals | |
| Conditions | Appeals will consider out-of-pocket expenses Appeals will consider total medical expenses Appeals may be made before the patient has been denied |
| Other Medications | |
| Other Medications available in this program | |
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