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Patient Assistance Information

 
1 Program for Boostrix vaccine
 
 
GSK Vaccines Access Program


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Phone : (877)822-2911
Fax: (877)822-1555
Eligibility
> Must have no health insurance for vaccine. Medicare Part D patients are not eligible for this program. Income must be at or below 250% of FPL. Must live in US or DC
Who Can Apply
> Call to have application faxed or mailed. Application must be returned via fax from Doctor's office. Health care provider notified via fax of decision usually the same day.
Required
> Diagnosis/Medical Criteria requires Patient to be 19yr old or older. Doctor must register with program, complete sections, obtain patients completed application with income documentation. Patient must provide prescriber signed application and income documentation.
Supply
> Amount/supply varies. Doctor/Doctor's office must complete replacement form for refills. Refill limit not specified. New application, new documentation to be completed yearly.
Ship To
> Ship to Doctor's office.
Note
> For the Cervarix vaccine, the patient must be female between 19-25 years old. This program does not constitute health insurance.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Boostrix vaccine