|
Patient Assistance Information
|
| |
|
6 Programs Sponsored By Merck & Co., Inc. (External Link)
|
| |
| |
Merck Vaccine Patient Assistance Program
|
,
Phone
:
800-293-3881
Fax:
800-528-2551
|
|
Eligibility
|
| > |
The patient must have no insurance and have an income at or below 200% of the Federal Poverty Level. The patient must be aged 19 or older. The patient must also be residing the US. Patients who do not meet these criteria may still qualify for this program if the patient has special circumstance of financial and medical hardship (but the upper income limit is $41,600 for individuals, $56,000 for couples, $84,800 for a family of four.) For vaccines that are multidoses, the process must be repeated for each dose. |
| Who Can Apply
|
| > |
Anyone requesting assistance can call to request a faxed application or download it from the website. |
|
Required
|
| > |
The doctor must fill out a section and sign the application.The patient must fill out a section and sign the application. |
|
Supply
|
| > |
|
|
Ship To
|
| > |
|
|
Note
|
| > |
Anyone requesting assistance can call to request a faxed application or download it from the website. |
| |
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.
| | Gardasil 9 vaccine | | Gardasil Injection | | M-M-R II Injection (measles, mumps and rubella virus vaccine live) | | Pneumovax 23 injeciton | | Recombivax HB Injection | | Vaqta | | Varivax Injection | | Zostavax Injection |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form | (Requires Acrobat Reader) 
|
| |
|
|
| |
Merck Connect
|
,
Phone
:
800-489-5119
Fax:
|
|
Eligibility
|
| > |
This program is for healthcare professionals only. Patient eligibility will be determined on a case by case basis. Income requirements for this program have not been disclosed. The medication must be medically necessary as determined by a doctor. The patient must be treated by a US licensed healthcare professional. |
| Who Can Apply
|
| > |
Patients can enroll online. |
|
Required
|
| > |
Doctors must enroll in the program. Patients must inform their doctor that they are in need. |
|
Supply
|
| > |
Up to a 30 day supply. |
|
Ship To
|
| > |
Not specified |
|
Note
|
| > |
Resources for HEALTHCARE PROFESSIONALS ONLY.
The Physician must register to access tools and materials for patient support, product sample requests, up-to-date professional resources, and other Merck professional sites. |
| |
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.
| | Asmanex HFA aerosol; inhalation | | Asmanex Twisthaler Inhalation Powder | | Belsomra tablet | | Dulera aerosol; inhalation | | Emend capsule | | Emend injection | | Follistim AQ Cartridge injection; subcutaneous | | Grastek tablet; sublingual | | Isentress tablet | | Janumet tablet | | Janumet XR tablet; extended release | | Januvia | | Nexplanon implant | | Noxafil tablet; delayed release | | Nuvaring vaginal ring | | Proventil HFA aerosol; inhalation | | Ragwitek tablet; sublingual | | Vytorin tablet | | Zepatier | | Zetia tablet | | Zontivity tablet |
| |
| |
|
|
| |
AccessSivextro Program
|
,
Phone
:
844-282-4782
Fax:
844-282-4783
|
|
Eligibility
|
| > |
This program is for healthcare providers only. Patients must be uninsured. Patients with Medicare Part D are not eligible. The medication must be medically necessary as determined by a doctor. Income requirements have not been disclosed for this program. Patients must be a US resident. |
| Who Can Apply
|
| > |
Doctors or the doctors office must call to have the application faxed or mailed or they can download the application. |
|
Required
|
| > |
Doctor's must complete, sign the application and attach required documents. Patients must complete their section and sign. |
|
Supply
|
| > |
Not specified |
|
Ship To
|
| > |
Not specified |
|
Note
|
| > |
This program is intended for US HEALTHCARE PROFESSIONALS and/or Professionals involved in Healthcare Reimbursement ONLY.
This program also provides copay assistance for patients with commercial insurance.
Merck Product Replacement Program: 1-866-363-6379 |
| |
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.
| | Sivextro tablet |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form | | (Requires Acrobat Reader)
|
| |
|
|
| |
AccessZerbaxa Program
|
,
Phone
:
844-282-4782
Fax:
844-282-4783
|
|
Eligibility
|
| > |
This program provides brand name medications at no or low cost. Patients must be uninsured. Patients with Medicare Part D are not eligible. Income requirements for this program have not been disclosed. Patients must be a US resident. |
| Who Can Apply
|
| > |
Doctor or doctor's office can call to have an application faxed or can download one. |
|
Required
|
| > |
Doctors must complete and sign the application. The patient must complete their section, sign and then the application can be faxed. |
|
Supply
|
| > |
Not specified |
|
Ship To
|
| > |
Not specified |
|
Note
|
| > |
This program only offers product replacement for product provided to patients who are completely uninsured if they meet other eligibility criteria. A product replacement form is required. |
| |
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.
| | Zerbaxa injection |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form | | Download printable Form | | (Requires Acrobat Reader)
|
| |
|
|
| |
AccessCubicin Program
|
PO Box 4280
Gaithersburg, MD 20897
Phone
:
844-282-4246
Fax:
866-428-2478
|
|
Eligibility
|
| > |
This program provides brand name medications at no or low cost. Patients must be uninsured. Medicare Part D recipients are not eligible. Income requirements for this program have not been disclosed. Medication must medically necessary as determined by a doctor. Patient must be a US resident. |
| Who Can Apply
|
| > |
Anyone interested can call to have an application faxed or download one. |
|
Required
|
| > |
Doctors must complete the application, sign and attach required documents. Patient must complete and sign their section and then the application can be faxed. |
|
Supply
|
| > |
Not specified |
|
Ship To
|
| > |
Not specified |
|
Note
|
| > |
|
| |
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.
| | Cubicin Injection |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form | | Download printable Form | | Download printable Form | | (Requires Acrobat Reader)
|
| |
|
|
| |
Merck Product Replacement Patient Assistance Program
|
PO Box 8122
Somerville, NJ 08876
Phone
:
866-840-5400
Fax:
877-923-6786
|
|
Eligibility
|
| > |
This program is for healthcare professionals only. Patients must be uninsured. Medicare Part D recipients are not eligible. Patients must have an FDA-approved diagnosis and must be residing in the US or a US territory. Patients must also be under the care of a US physician. |
| Who Can Apply
|
| > |
The doctor or doctor's office must call to obtain an application. |
|
Required
|
| > |
Patients must inform the doctor that they are in need of assistance. The doctor or doctor's office must call. |
|
Supply
|
| > |
Varies |
|
Ship To
|
| > |
Doctor's office or specific site. |
|
Note
|
| > |
|
| |
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.
| | Cancidas injectable; iv | | Invanz injection | | Primaxin IM injection | | Primaxin injection |
| |
| |
|
|
|
|
|