Benlysta

Indicated For

systemic lupus erythematosus (SLE), lupus nephritis (LN)

About This Medication

# GSK Patient Assistance Program (PAP) for BENLYSTA Patient Guide: How to Get BENLYSTA at Low or No Cost ## About BENLYSTA BENLYSTA (belimumab) is a prescription medication used to treat systemic lupus erythematosus (SLE) and lupus nephritis. As a specialty medicine, BENLYSTA can be expensive, which is why GlaxoSmithKline (GSK) offers a Patient Assistance Program to help eligible patients access this medication at no cost. ## Who Can Qualify for This Program? The GSK Patient Assistance Program for BENLYSTA is designed for patients who: - Are **uninsured** or have insurance that does not cover BENLYSTA - Are **Medicare patients** who meet specific eligibility requirements - Are **functionally uninsured** (have insurance with high out-of-pocket costs) - Live in the United States, Puerto Rico, or the U.S. Virgin Islands - Have a valid prescription for BENLYSTA from a healthcare provider If you have commercial insurance that covers BENLYSTA, you may qualify for the **BENLYSTA Copay Program** instead, which helps reduce your out-of-pocket costs. Contact BENLYSTA Gateway for more information about which program is right for you. ## Income Eligibility Requirements To qualify for the Patient Assistance Program, your household income must fall below the maximum thresholds listed below. These thresholds are set at 400% of the federal poverty level. | Household Size | Maximum Annual Gross Income | |---|---| | 1 person | $78,200 | | 2 people | $105,720 | | 3 people | $133,240 | | 4 people | $160,760 | | Each additional person | Add $27,520 | **Important:** If your income exceeds these limits, you may still qualify if your eligible medical expenses bring your household income below the threshold. This is called the "medically needy allowance." Contact the program directly to discuss your situation. ## Insurance Requirements You are eligible for this program if you: - Have **no health insurance** (uninsured) - Are a **Medicare patient** who meets program requirements - Have insurance that does not cover BENLYSTA You are **NOT eligible** if you have: - Medicare Part D prescription drug coverage - Medicaid - Veterans Affairs (VA) benefits - TRICARE or Department of Defense (DoD) coverage - State pharmaceutical assistance programs - Other federal or state-funded prescription insurance programs If you are unsure about your insurance status, contact the program for clarification. ## How to Apply: Step-by-Step ### Step 1: Gather Required Documents Before you apply, collect the following: - **Proof of income** (recent tax return, pay stubs, or benefit statements) - **Proof of residency** (utility bill, lease, or government ID) - **Valid prescription** for BENLYSTA from your doctor - **Insurance information** (if applicable) - **HIPAA release form** (provided with application) - **Medicare Beneficiary Identifier (MBI)** if you are a Medicare patient ### Step 2: Complete the Enrollment Form Download and complete the BENLYSTA Enrollment Form, available at the program website. The form asks for: - Your personal information - Household size and annual pretax income - Insurance details - Your prescription information - Authorization for the program to contact your healthcare provider ### Step 3: Submit Your Application Submit your completed form along with supporting documents. You can apply through: - **Online:** Visit GSKForYou.com or the BENLYSTA website - **Mail:** Send your application to the address provided on the enrollment form - **Healthcare provider:** Your doctor's office may submit the application on your behalf ## Timeline and Delivery **Processing Time:** Your application is typically reviewed and processed within **2 weeks**. **Notification:** You will be notified of your eligibility status by mail or phone. **Delivery:** Once approved, BENLYSTA will be shipped directly to you or your healthcare provider's office. Your healthcare provider will administer the medication if it is the intravenous (IV) form, or you may self-administer if it is the subcutaneous (SC) form. ## What Happens If Your Application Is Denied? If you are denied: 1. **Ask why:** Request a detailed explanation of the denial reason 2. **Review your information:** Check that all income and insurance information was accurate 3. **Appeal:** Ask if you can provide additional documentation or appeal the decision 4. **Explore alternatives:** Ask about the BENLYSTA Copay Program or other assistance options 5. **Contact BENLYSTA Gateway:** This support service can help investigate your coverage options and may assist with reapplication ## Reauthorization and Refills Your eligibility in the Patient Assistance Program must be **reauthorized annually**. This means: - You will need to reapply each year to continue receiving assistance - Your income and household size may change, affecting eligibility - The program will contact you when reauthorization is needed - Keep your contact information current with the program ## Additional Support Services **BENLYSTA Gateway** is a free support service that can help you: - Investigate your insurance coverage and out-of-pocket costs - Research prior authorization requirements - Determine which financial assistance program is right for you - Follow up on your application status Contact BENLYSTA Gateway through your healthcare provider or the BENLYSTA website. ## Important Disclaimer This guide provides general information about the GSK Patient Assistance Program for BENLYSTA. Program eligibility, terms, and conditions are subject to change. This program does not constitute health insurance. For the most current and complete information, visit GSKForYou.com or contact the program directly. Always consult with your healthcare provider about your treatment options and financial assistance eligibility.

Program information last verified: March 25, 2026