GSK Patient Assistance Program for Vaccines

The GSK Vaccines Patient Assistance Program is for patients who need financial assistance with a GSK vaccine. This program does not constitute health insurance.

The following vaccines are currently included in the program:

BOOSTRIX (Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine, Adsorbed)
ENGERIX-B [Hepatitis B Vaccine (Recombinant)]
SHINGRIX (Zoster Vaccine Recombinant, Adjuvanted)

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Eligibility

To qualify for the GSK Patient Assistance Program for Vaccines, you must:

Have no third party coverage for Vaccines
Be an adult, 18 or older
Live in the United States or Puerto Rico
Not be eligible for Puerto Rico's Government Health Plan Mi Salud or have applied and been denied

Medicare patients are not eligible for the GSK PAP Vaccines Program.

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

48 States and DC
Household Size	Maximum Annual Gross Income
1	$46,950
2	$63,450
3	$79,950
4	$96,450
For each additional person, add	$16,500

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	$58,650
2	$79,290
3	$99,930
4	$120,570
For each additional person, add	$20,640

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	$53,970
2	$72,960
3	$91,950
4	$110,940
For each additional person, add	$18,990

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	$28,800
2	$36,000
3	$43,200
4	$50,400
For each additional person, add	$7,200

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

Enrollment

You must enroll in the GSK Patient Assistance Program through your healthcare provider.

Your healthcare provider will need to first register with the program. Your healthcare provider will submit your application.
Assistance is available in Spanish and many other languages: 1-866-728-4368
La asistencia está disponible en español y muchos otros idiomas: 1-866-728-4368

For Healthcare Providers

Prior to enrolling patients, prescribers must register in the program.
For patient enrollment, prescribers may fax the completed and signed application to 1-855-474-3063 or submit through the provider portal via GSK Patient Assistance Program Portal. Once approved, the applicant will be eligible to received vaccine for up to one year.
Once enrolled, the patient may receive subsequent doses of vaccine by having the prescriber complete the Dose Authorization Request Form.

Updated application forms now available

You may call 1-866-728-4368 to request an application by mail, or download a program application here:

*
Subject to eligibility, program terms, and conditions, which are subject to change. Programs do not constitute health insurance.

Are you uninsured or have Medicare?

Get help paying for certain GSK products if you’re eligible.

CHECK ELIGIBILITY

Have private insurance?

See access and copay assistance programs for certain products.

SEE DETAILS