GlaxoSmithKline: VAP Patient Eligibility

Patient Eligibility

Patients who meet the following criteria may be eligible for GSK Vaccines Access Program:

The patient has no health insurance for vaccines,
The patient is an adult, age 19 or older, or a female between 19 and 25 for Cervarix,
The patient lives in one of the 50 states or the District of Columbia, and
The patient has an annual household income less than or equal to 250% of the federal poverty level, adjusted by household size.

Income limits

	Maximum Monthly Gross Income
Household Size	48 States and D.C.	Alaska	Hawaii
1	$2,393.75	$2,989.58	$2,756.25
2	$3,231.25	$4,037.50	$3,718.75
3	$4,068.75	$5,085.42	$4,681.25
4	$4,906.25	$6,133.33	$5,643.75
For each additional person, add	$837.50	$1,047.92	$962.50
Calculate your monthly income limit if you have more than 4 people in your household

Proof of Household Income
Send in proof of current income and other requested documents along with the completed and signed application and a prescription with refills if medically appropriate for mail order refills.

If the applicant filed income tax or was listed as a dependent on someone else's income tax for the most recently filed tax year, attach a copy of page one of the tax form.

If no tax was filed or if the tax form does not represent current income, attach proof of income from all sources for the most recent 30-day period for the applicant and all members of the household. Please provide copies, not originals, of pay stubs, unemployment stubs, Social Security statements, pension statements, and any other sources of income. The following are examples of acceptable proof of income:

Income tax form:

A copy of page 1 of the most recently filed 1040, 1040A or 1040EZ tax return

Salary/wages:

One month consecutive salary/income documentation
A copy of a pay stub with year-to-date income
Letter indicating salary/wages on company letterhead
Notarized statement from employer
Bank statement showing salaries and wages deposited by employer

Self employment income:

1099 form including Schedule C from the most recent tax return
Copy of most recent check or check stub

Social Security Retirement:

Benefit statement for current year
Copy of most recent bank statement showing direct deposit
Copy of most recent check or check stub

Supplemental Security Income:

Benefit statement for current year
Copy of most recent bank statement showing direct deposit
or copy of most recent check or check stub

Social Security Disability:

Benefit statement for current year
Copy of most recent bank statement showing direct deposit
Copy of most recent check or check stub

Unemployment:

Unemployment award letter on company letterhead indicating amount and time period covered
Copy of most recent unemployment check or unemployment check stub

Alimony/Child support:

Court award letter indicating amount and time period covered
Child Support Enforcement Agency letter
Letter from attorney stating amount and time period covered
Copy of one month's check
Bank statement with amount indicated

Veterans Benefits:

Benefit statement or current year
Copy of most recent bank statement showing direct deposit
Copy of most recent check
Check stub

Pension/Retirement:

Benefit statement for current year
Copy of most recent bank statement showing direct deposit
Copy of most recent check
Check stub

Other:

Benefits statement
Award letter
Bank statement from payer/source
Copy of check(s)
Judgment statement