| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | ||||||
View Coupon |
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GSK Vaccines Access Program |
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Provided by: GlaxoSmithKline |
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TEL: Closed Program |
Languages Spoken:
English, Spanish, Others By Translation Service
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Patient Assistance Applications |
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Generic Name Medications |
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Eligibility Requirements |
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| Insurance Status | Must have no health insurance for vaccine | |||||
| Those with Part D Eligible? | No | |||||
| Income | At or below 250% of FPL | |||||
| Diagnosis/Medical Criteria | Must be 19 yr old or older | |||||
| US Residency Required? | Must live in US or DC | |||||
Application |
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| Obtaining | Call | |||||
| Receiving | Faxed or mailed | |||||
| Returning | Fax from Doctor's office | |||||
| Doctor's Action | Register with program, complete sections, obtain patients completed application with income documentation | |||||
| Applicant's Action | Provide prescriber signed application and income documentation | |||||
| Decision Communicated | Health care provider notified via fax | |||||
| Decision Timeframe | Within 1-2 business days | |||||
Medication |
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| Amount/Supply | Varies | |||||
| Sent To | Doctor's office | |||||
| Delivery Time | Not applicable | |||||
| Refill Process | Doctor/Doctor's office must complete replacement form | |||||
| Limit | Not specified | |||||
| Re-application | New application, new documentation yearly | |||||
Additional Information |
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| Closed Program This program does not constitute health insurance. |
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| Updated November 14, 2017 | ||||||
