If You Have Medicare

This section provides information about the BENLYSTA Patient Assistance Program for patients with Medicare prescription coverage.

An older couple enjoys sitting by the water

Eligibility

To qualify for the BENLYSTA Patient Assistance Program, you must:

Live in the United States, Puerto Rico or US Virgin Islands
Have a Medicare prescription drug plan
Not be enrolled in Medicare Extra Help (Low Income Subsidy) Program
Not be currently receiving prescription drug coverage through a government Program (excluding Medicare), which includes Medicaid, VA, DOD or TriCare benefits
Not be eligible for Puerto Rico's Government Health Plan Mi Salud, or have applied and been denied

You must also meet certain income eligibility requirements as outlined below:

Patients whose income exceeds program eligibility maximum will be provided the opportunity to demonstrate that their eligible medical expenses bring them within the income eligibility criteria (please contact program for details).

48 States and DC
Household Size	Maximum Annual Gross Income
1	$60,240
2	$81,760
3	$103,280
4	$124,800
For each additional person, add	$21,520

Calculate your annual income limit if you have more than 4 people living in your household, including yourself.

Alaska
Household Size	Maximum Annual Gross Income
1	$75,240
2	$102,160
3	$129,080
4	$156,000
For each additional person, add	$26,920

Calculate your annual income limit if you have more than 4 people living in your household, including yourself.

Hawaii
Household Size	Maximum Annual Gross Income
1	$69,240
2	$94,000
3	$118,760
4	$143,520
For each additional person, add	$24,760

Calculate your annual income limit if you have more than 4 people living in your household, including yourself.

Puerto Rico
Household Size	Maximum Annual Gross Income
1	$48,000
2	$60,000
3	$72,000
4	$84,000
For each additional person, add	$12,000

Calculate your annual income limit if you have more than 4 people living in your household, including yourself.

For assistance with the BENLYSTA Patient Assistance Program please call 1-877-423-6597

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Enrollment

You can enroll in the program in 3 steps:

Complete the Enrollment form
- Complete and print the form below:
  - BENLYSTA Enrollment Form – English
  - BENLYSTA Enrollment Form – Spanish
Sign the form
- Both the patient and the provider must sign and date the form
Return the completed form to the BENLYSTA Gateway
- Follow the instructions on your Enrollment form
  - The GSK Patient Assistance Program
    PO Box 5490
    Louisville, KY 40255
    1-877-423-6597