Eligibility criteria
Patients may be eligible based on general eligibility criteria below:

• Patient has a commercial medical or prescription insurance plan;

AND

• Patient is a resident of the US (including the District of Columbia, Puerto Rico, and the US Virgin Islands); and
• Not eligible for or enrolled in a government funded program that provides prescription drug coverage*

To determine if a patient is eligible for the BENLYSTA (herein "GSK") Copay Program, an enrollment form must be completed and submitted to the Copay Program.  The Copay Program will evaluate the patient for eligibility and communicate eligibility to the patient and provider. Eligibility in the GSK Copay Program is assessed annually. Patients must qualify for the Copay Program each year that they wish to participate in the Program. Final patient eligibility determinations are provided by the GSK Copay Program.

• The assistance provided by the GSK Copay Program is offered to, and intended for the sole benefit of eligible patients and may not be transferred to or utilized for the benefit of third parties, including, without limitation, third party payers, pharmacy benefit managers, or the agents of either.
• The value of the GSK Copay Program is exclusively for the benefit of enrolled patients and is intended to be credited toward patient out-of-pocket responsibilities (e.g., copayments, coinsurance, annual deductibles, and annual out-of-pocket maximums).
• The assistance provided by the GSK Copay Program cannot be combined with any other assistance program, free trial, discount, prescription savings card, or other offer.
• Patients must have a prescription for the GSK Product in order to apply for the GSK Copay Program. If a patient's prescription drug coverage is provided by a private commercial payer and the commercial payer has opted out of the GSK Copay Program, the patient is not eligible to participate.
• The GSK Copay Program is not insurance. GSK reserves the right to rescind, revoke, or amend this offer without notice at any time. Offer good only in the United States (including the District of Columbia, Puerto Rico and the US Virgin Islands). Void where prohibited, taxed, or otherwise restricted by law.
• Patients should inform Program representatives of any changes in insurance coverage during the course of enrollment in the GSK Copay Program.

*Patients are not eligible for this program if they are covered by any federal or state prescription insurance program. This includes patients enrolled in Medicare Part B, Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DoD) programs or TriCare. This may also include state pharmaceutical assistance programs and other federal or state plans not listed. 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. 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. Those on Medicare Part D, even if in the coverage gap, are not eligible. Patients enrolled in private indemnity or HMO insurance plans that reimburse them for the entire cost of their prescription drugs are also not eligible.

Program Details
If the patient is approved, the GSK Copay Program may help with the patient's cost share for BENLYSTA and the patient’s cost share for administration up to the total annual Copay Program Maximums described below. Residents of Massachusetts, Minnesota or Rhode Island, are not eligible for reimbursement of administrative fees. Doctor's office visits, labs, and other ancillary services are not included in the Copay Program.

The Copay Program Maximum for patients who are enrolled in an insurance plan that credits the amount of the GSK Copay Program toward their plan out-of-pocket responsibilities for BENLYSTA (e.g., copayments, coinsurance, annual deductibles, and annual out-of-pocket maximums) is $9,450 annually. The Copay Program Maximum for patients determined to be enrolled in high deductible health plans is up to $15,000 annually.

The Copay Program Maximum for patients who are enrolled in maximizer plans is $5,000 annually. A maximizer plan is an insurance plan that sets an individual’s cost-sharing amount at the maximum value of the manufacturer’s copay assistance. Maximizer plans do not credit the amount of the GSK Copay Program toward the patient’s deductible and annual out-of-pocket maximums.

The Copay Program Maximum for administration of the product is $100 per administration and counts towards the annual copay program maximums as described above.