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Patient Assistance Information

 
4 Programs Sponsored By Merck Sharp & Dohme Corp., a subsidiary of Merck & Co. (External Link)
 
 
SUPPORT Program for Crixivan

SUPPORT Program
PO Box 305
San Bruno, CA 94066
Phone : 800-850-3430
Fax: 866-410-1913
Eligibility
> This program provides brand name medications at no or low cost to patients. Patients may have insurance and Medicare Part D recipients will be considered on a case by case basis. Patients must be at or below 500% of the federal poverty level. Patients must live in the US and have a prescription from a US licensed doctor.
Who Can Apply
> Anyone interested can call or download an application.
Required
> Doctors and patients must complete and sign the application and mail it back.
Supply
> Varies
Ship To
> Doctor's office, pharmacy or patient's home
Note
> Insurance benefits, claims assistance and/or other reimbursement help is offered. Exceptions to guidelines considered. This Program participates in the CPAPA. This single common application allows uninsured HIV-positive individuals with low incomes to use one application to apply for multiple assistance programs. IMPORTANT: Send completed CPAPA to the corresponding addresses listed for each company.
 
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.
 
Crixivan Capsules
 
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
 
 
ACT Program

ACT Program
PO Box 18979
Louisville, KY 40261
Phone : 866-363-6379
Fax: 866-363-6389
Eligibility
> This program provides brand name medications at no or low cost to patients that are uninsured or underinsured. Medicare Part D recipients are eligible. Patients must be at or below 500% of the federal poverty level. Patients must be a US resident and be treated by a US licensed healthcare provider.
Who Can Apply
> Anyone interested can call or download an application and it will be faxed, emailed or mailed to them.
Required
> Doctors must complete, sign and attach a prescription to the application. Patients must complete and sign and the completed application can be sent by fax or mail.
Supply
> Up to 30 day supply
Ship To
> Doctor's office or patient's home
Note
> Patients in need who appear not to qualify should still call.
 
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.
 
Noxafil tablet; delayed release
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader
 
 
SUPPORT Program for Isentress

SUPPORT Program
PO Box 305
San Bruno, CA 94066
Phone : 800-850-3430
Fax: 866-410-1913
Eligibility
> This program provides brand name medications at no or low cost to patients. Patients with insurance are eligible and Medicare Part D recipients will be considered on an exception basis. Patients must be at or below 500% of the federal poverty level. They must also live in the US and have a prescription from a US licensed doctor.
Who Can Apply
> Anyone interested in the program can call or download an application.
Required
> Doctors and Patients must complete and sign their portions of the application and it can returned by mail.
Supply
> Varies
Ship To
> Doctor's office or patient's home
Note
> nsurance benefits, claims assistance and/or other reimbursement help is offered. Exceptions to guidelines considered. This Program participates in the CPAPA. This single common application allows uninsured HIV-positive individuals with low incomes to use one application to apply for multiple assistance programs. IMPORTANT: Send completed CPAPA to the corresponding addresses listed for each company.
 
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.
 
Isentress oral suspension; granule
Isentress tablet
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
Download printable Form
(Requires Acrobat Reader
 
 
Entereg Access Support and Education (E.A.S.E.)


,
Phone : 877-282-4786 Ext opt4
Fax: 800-278-1365
Eligibility
> This program is for healthcare professionals only. Insurance, income and residency requirements have not been disclosed for this program.
Who Can Apply
> The doctor or the doctor's office must call or download an application.
Required
> The patient must inform the doctor that he or she is in need. The hospital contact must complete, sign and fax the form.
Supply
> Varies
Ship To
> Hospital
Note
> Resources for HEALTHCARE PROFESSIONALS ONLY. Entereg is available only to hospitals that enroll in the E.A.S.E. Program and is available only for short-term (15 doses) use in hospitalized patients.
 
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.
 
Entereg capsule
 
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