Final patient eligibility determinations are provided by the Together with GSK Oncology HUB. Patients must apply for Co-pay assistance each year that they wish to participate in the Program. Eligibility in the Together with GSK Oncology Co-pay Program is for one year. Once the application is received, the Together with GSK Oncology Co-pay Program will evaluate the patient for eligibility and communicate eligibility. The enrollment form can be downloaded online at. Visit, select ZEJULA and click “apply” under Co-pay Assistance.Submit an Enrollment Form which can be downloaded online at, or.

To determine if your patient may be eligible for the Together with GSK Oncology Co-pay Program, you and your patient will need to complete the program application.

Not eligible for or enrolled in government funded programs that provide prescription drug coverage*.

Are a resident of the US (including the District of Columbia, Puerto Rico, and the US Virgin Islands) and.

Patients have a commercial medical or prescription insurance plan or.

Patients should inform Program representatives of any changes in insurance coverage during the course of enrollment in the GSK Co-pay Program. Doctor's office visits, labs, and other ancillary services are not included in the Co-Pay Program.

Residents of Massachusetts, Minnesota or Rhode Island, are not eligible for reimbursement of administrative fees. If the patient is approved, the GSK Co-pay Program may help with the patient's cost share for the GSK product, and the cost of administration, up to $100 per administration, up to a program total of $15,000 annually. Void where prohibited, taxed, or otherwise restricted by law. Offer good only in the United States (including the District of Columbia, Puerto Rico and the US Virgin Islands). GSK reserves the right to rescind, revoke, or amend this offer without notice at any time. If patient's prescription drug coverage is provided by a private commercial payer and the commercial payer has opted out of the GSK Co-pay Program, the patient is not eligible to participate. Patients must have a prescription for the GSK Product in order to apply for the GSK Co-pay Program. Patients enrolled in private indemnity or HMO insurance plans that reimburse them for the entire cost of their prescription drugs are also not eligible. Those on Medicare Part D, even if in the coverage gap, are not eligible. 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 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. This may also include state pharmaceutical assistance programs and other federal or state plans not listed. This includes patients enrolled in Medicare Part B, Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DoD) programs or TriCare. *Patients are not eligible for this program if they are covered by any federal or state prescription insurance program. Final patient eligibility determinations are provided by the GSK Co-pay Program. Patients must qualify for the Co-pay Program each year that they wish to participate in the Program. Eligibility in the GSK Co-pay Program is for one year. The Co-pay Program will evaluate the patient for eligibility and communicate eligibility to the patient and provider. To determine if a patient is eligible for the BENLYSTA or NUCALA (herein 'GSK') Co-pay Program, an enrollment from must be completed and submitted to the Co-pay Program. Not eligible for or enrolled in a government funded program that provides prescription drug coverage*.Patient is a resident of the US (including the District of Columbia, Puerto Rico, and the US Virgin Islands) and.Patient has a commercial medical or prescription insurance plan or.Patients may be eligible based on general eligibility criteria below:

Copay assistance