If You Are Uninsured

This section provides information about the ZEJULA Patient Assistance Program for patients who do not have insurance, or whose insurance does not cover the product (please contact program for Functionally Uninsured eligibility process details).

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Eligibility

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

Live in the United States, Puerto Rico or US Virgin Islands
Meet one of these criteria:
- Uninsured
- Have private commercial insurance but have no coverage (medical or pharmacy) for the product as demonstrated to the program through the defined Appeals Process criteria (please contact program for details)
Not be enrolled in an Alternate Funding 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 ZEJULA Patient Assistance Program please call Together with GSK Oncology at 1-844-4GSK-ONC (1-844-447-5662)

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Enrollment

You can enroll in the program in 3 steps:

Complete the Enrollment form
- Complete and print the form below:
  - ZEJULA Enrollment Form
Sign the form
- Both the patient and the provider must sign and date the form
Return the completed form to Together with GSK Oncology
- Follow the instructions on your Enrollment form
  - The GSK Patient Assistance Program
    PO Box 5490
    Louisville, KY 40255
    1-844-447-5662