Trelegy Ellipta

GSK Patient Assistance Program Patient Guide: How to Get Trelegy Ellipta at Low or No Cost

About This Program

The GSK Patient Assistance Program (PAP) provides Trelegy Ellipta at no cost to eligible patients who struggle to afford their medications.[1] This program is managed by the GSK Patient Access Programs Foundation, an independent 501(c)(3) charitable foundation separate from GSK.[1] Trelegy Ellipta is a combination inhaler containing fluticasone furoate, umeclidinium, and vilanterol, used to treat chronic obstructive pulmonary disease (COPD).

Who Qualifies for This Program?

To be eligible for the GSK Patient Assistance Program, you must meet these requirements:

Residency and Insurance Status

• Live in the United States or Puerto Rico[4]
• Be uninsured or enrolled in Medicare Part D[6]
• Not be enrolled in other government health programs (such as Puerto Rico's Mi Salud plan)[4]

Income Requirements

You must meet household income limits based on family size. The following table shows the maximum annual gross income thresholds for uninsured patients:[6]

Medicare Part D Patients

If you have Medicare Part D coverage, you must also have paid at least $600 out-of-pocket for prescriptions in the current calendar year.[4]

About Trelegy Ellipta

Trelegy Ellipta is a prescription maintenance inhaler for adults with COPD. It combines three active ingredients that work together to help open airways and reduce inflammation. Your doctor will determine if Trelegy Ellipta is the right medication for your condition.

How to Apply

Step 1: Gather Required Documents

Before starting your application, collect the following:[2][3]

• A signed prescription from your healthcare provider for Trelegy Ellipta (original prescriptions only; faxed prescriptions are accepted only if sent directly from a physician's office with a fax cover sheet)[2]
• Proof of income (such as recent pay stubs, tax returns, or benefit statements)
• Proof of residency (such as a utility bill or lease agreement)
• For Medicare Part D patients: Your Medicare Part D ID card and proof that you've spent $600 on prescriptions (your Explanation of Benefits statement from your prescription drug plan)[3]

Step 2: Complete the Application

You can apply in two ways:

1. By Phone: Call 1-866-728-4368 to request an application or apply directly[4]
2. By Mail or Fax: Request the GSK Patient Assistance Program enrollment application and submit it with all required documents

When completing the application, you must:[2][3]

• Fill out all required sections completely
• Provide your personal information, household size, and total gross monthly or annual income
• List the GSK medication(s) you're requesting (Trelegy Ellipta)
• Sign and date the last page
• Keep a copy for your records

Important: An incomplete application will delay processing.[2]

Step 3: Submit Your Application

Fax or mail your completed application along with all required documents. Do not send original documents—they will not be returned.[2]

Timeline and Medication Delivery

Processing Time

• Applications submitted by phone or fax may receive urgent processing
• Standard processing typically takes several weeks
• Once approved, you may receive coverage for up to 12 months[1]

How You'll Receive Your Medication

Once approved, Trelegy Ellipta will be shipped to your pharmacy or directly to your healthcare provider for you to pick up.[1] You will not pay for the medication.

Reauthorization

Your eligibility for the program must be reauthorized periodically. You may need to submit updated income documentation or other information to continue receiving medication at no cost. The program will contact you when reauthorization is needed.

What If Your Application Is Denied?

If your application is denied, you have several options:

• Ask why: Contact the program at 1-866-728-4368 to understand the reason for denial
• Explore alternatives: The program may help you find other funding sources, including:
  • State pharmaceutical assistance programs
  • Nonprofit organizations that help with medication costs
  • Other insurance options
  • Social services in your area[3]
• Reapply: If your circumstances change (such as income decreasing), you may reapply

Important Information About Your Privacy

When you apply, you authorize GSK and its administrators to:[3]

• Use your information to determine eligibility and administer the program
• Contact your doctor, healthcare provider, or pharmacist about your application
• Request information from your insurance company or other funding sources
• Obtain a consumer report on you

Your information is used only to help you receive medication and ensure program guidelines are met.

Questions?

For questions about the GSK Patient Assistance Program, call 1-866-728-4368. Program staff can help you understand eligibility, complete your application, and answer questions about the process.

Disclaimer

This guide provides general information about the GSK Patient Assistance Program. Program eligibility, requirements, and benefits are subject to change. This program does not constitute health insurance. For the most current and complete information, contact the program directly or visit GSKForYou.com. Always consult with your healthcare provider about your medication needs and treatment options.