Eligibility Criteria: Open to patients with an HIBSAGO prescription and commercial insurance for HIBSAGO. Patients may not seek reimbursement for value received from the HIBSAGO Copay Program from any third-party payers, including a flexible spending account or healthcare savings account. This program is not open to uninsured patients or patients receiving prescription reimbursement under any federal, state, or government-funded healthcare program, such as Medicare, Medicare Advantage, Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), the Department of Defense (DoD), or TRICARE, or where prohibited by law. If at any time patients begin receiving prescription drug coverage under any such federal, state, or government-funded healthcare program, patients will no longer be able to use this card and you must call the HIBSAGO Copay Program at 1-844-817-1220 (9:00 am-8:00 pm ET, Monday-Friday) to stop participation. Restrictions may apply. GSK reserves the right to revise or terminate this program, in whole or in part, without any notice at any time. This is not health insurance. Program invalid where otherwise prohibited by law.

Program Details: The HIBSAGO Copay Program provides financial support for eligible commercially insured patients. The program does not provide support for supplies, procedures, or any physician-related services associated with HIBSAGO. For eligible patients, the program covers the amount of OOP cost for HIBSAGO that exceeds $25 for each dose, up to a maximum benefit of $8,000 per patient, per calendar year. Patient is responsible for costs above this amount. Patient card is reset every January 1. Patients need to re-verify their eligibility on a yearly basis.