IMPORTANT NOTICE FOR BOOSTRIX, CERVARIX AND HAVRIX - VACCINES ACCESS PROGRAM ONLY:

The GSK Vaccines Access Program has temporarily suspended enrollment of patients into our Program for Cervarix as of 9/15/2014.  This temporary suspension has been caused by a product supply issue that has been identified. This issue only affects the Cervarix package of 1, which is only available for the Vaccines Access Program. This shortage does not have any effect on the supply of Cervarix in the commercial market. We apologize for any inconvenience.

Effective 9/17/2014 Havrix is available again in the GSK Vaccines Access Program.

Effective 11/5/2014 Boostrix is available again in the GSK Vaccines Access Program

All updates on program status will be posted to this website.  Questions regarding the GSK Vaccines Access Program can be addressed by calling Program representatives at 1–877–VACC–911, M–F, 9:00am–7:00pm ET.

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
$2,431.25
$3,037.50
$2,795.83
2
$3,277.08
$4,095.83
$3,768.75
3
$4,122.91
$5,154.16
$4,741.67
4
$4,968.74
$6,212.49
$5,714.59
For each additional person, add
$845.83
$1,058.33
$972.92
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 on company letterhead indicating salary/wages with the employer’s handwritten signature; letter must be dated and include a phone number and/or complete address
    • 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
This website is funded and developed by GlaxoSmithKline.
This site is intended for US healthcare professionals only.
© 1997-2014 GlaxoSmithKline. All Rights Reserved.
Legal Notices | Privacy Statement | Contact Us