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Merck Patient Assistance Program
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PO Box 690
Horsham, PA 19044
Phone
:
800-727-5400
Fax:
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Eligibility
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This program provides brand name medications at no or low cost. Patient eligibility will be determined in a case by case basis. Medicare Part D recipients are eligible. Patients must be at or below 400% of the federal poverty level. Patients must be a US resident. |
| Who Can Apply
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Anyone interested can call or download the application. |
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Required
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Doctors and patients must complete and sign the application. The original application must be mailed NOT faxed. A new application is needed yearly. |
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Supply
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90 day supply with up to 3 refills, for a total of up to 1 year of medications. Patients can request refills via a toll-free number. |
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Ship To
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Doctor's office or patient's home |
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Note
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At Merck we realize that sometimes exceptions need to be made based on the patient's individual circumstances. Individuals who do not meet the insurance criteria may still qualify for the Merck Patient Assistance Program if they attest that they have special circumstances of financial hardship, and their income meets the program criteria.
*The Enrollment Form must be mailed. Please do not fax. |
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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.
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| Asmanex HFA aerosol; inhalation |
| Asmanex Twisthaler powder; inhalation |
| Avelox Tablets |
| Belsomra tablet |
| Clarinex Tablets |
| Diprolene cream |
| Diprolene lotion |
| Diprolene ointment |
| Dulera aerosol; inhalation |
| Elocon Cream (mometasone furoate) |
| Elocon Lotion (mometasone furoate) |
| Foradil Aerolizer |
| Grastek tablet; sublingual |
| Janumet tablet |
| Janumet XR tablet; extended release |
| Januvia tablet |
| Maxalt MLT Tablets |
| Maxalt Tablets |
| Nasonex Nasal Spray |
| Nitro-Dur Patch |
| Proventil HFA Inhaler |
| Ragwitek tablet; sublingual |
| Singulair granule; oral |
| Stromectol Tablets |
| Temodar capsule |
| Trusopt Ophthalmic Solution |
| Vytorin tablet |
| Zetia tablet |
| Zolinza Capsules |
| Zontivity tablet |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form |
| Download printable Form |
(Requires Acrobat Reader) 
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Merck Access Program for Keytruda
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PO Box 29067
Phoenix, AZ
Phone
:
855-257-3932
Fax:
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Eligibility
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Patients must be uninsured or underinsured. Medicare Part D recipients are not eligible. Patients must be at or below 500% federal poverty level. A diagnosis code must be provided and patients must be treated by a US doctor. |
| Who Can Apply
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Anyone interested can call or download an application. |
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Required
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Doctors and patients must complete and sign the application and it can be returned by fax or mail. |
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Supply
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Up to 30 day supply |
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Ship To
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Doctor's office or patient's home |
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Note
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This program also provides copay assistance. |
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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.
|
| Keytruda |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| Download printable Form |
| (Requires Acrobat Reader)
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Merck Access Program
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PO Box 29067
Phoenix, AZ 85038
Phone
:
855-257-3932
Fax:
855-755-0518
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Eligibility
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This program provides brand name medications at no or low cost to patients that are uninsured or underinsured. Medicare Part D recipients are not eligible. Patients must be 500% below the federal poverty level. A diagnosis code must be provided and the patient must be treated by a US doctor. |
| Who Can Apply
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Anyone interested can call or download the application. |
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Required
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Doctors must complete, sign and attach a prescription. Patients must also complete and sign. Application can then be faxed or mailed. |
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Supply
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Up to 30 day supply |
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Ship To
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| > |
Doctor's office or patient's home |
|
Note
|
| > |
At Merck we realize that sometimes exceptions need to be made based on the patient's individual circumstances. Individuals who do not meet the insurance criteria may still qualify for the Merck Patient Assistance Program if they attest that they have special circumstances of financial hardship, and their income meets the program criteria. |
| |
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.
|
| Emend injection |
| Intron A vial |
| Sylatron syringe |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| (Requires Acrobat Reader)
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Merck Access Program for Zepatier
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PO Box 29067
Phoenix, AZ 85038
Phone
:
866-251-6013
Fax:
800-803-3104
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Eligibility
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This program is intended for patients that have no prescription coverage for the needed medication. Medicare Part D recipients will be considered on an exception basis. Income requirements for this program have not been disclosed. Patients must have a medically appropriate diagnosis or condition. Patients must also reside in the US, be under the direct care of a licensed US physician and receive US health care services. |
| Who Can Apply
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Anyone interested can call or download an application. |
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Required
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Doctors must complete and sign the application. Patients must also complete and sign the application. Once complete, it can be faxed in. |
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Supply
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Not specified |
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Ship To
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Not specified |
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Note
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|
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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.
|
| Zepatier |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| (Requires Acrobat Reader)
|
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