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Bayer Patient Assistance Program
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6 West Belt
W66
Wayne, NJ 07470-6806
Phone
:
888-842-2937
Ext OPT 7 or 3
Fax:
973-305-3545
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Eligibility
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The patient cannot have prescription insurance, be ineligible for any federal or state programs and the patient must also also have limited financial resources. The patient must be a US citizen or legal US resident. |
| Who Can Apply
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The patient or doctor should call for an application. |
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Required
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The doctor must fill out a section and sign the application.The patient must fill out a section, sign the application and attach proof of income. |
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Supply
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Up to a 90-day supply |
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Ship To
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Doctor's office |
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Note
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The patient or doctor should call for an application. |
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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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| Avelox Tablets |
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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 Application Form |
| Download printable Form Angeliq Form |
| Download printable Form Climara Form |
| Download printable Form Climara Pro Form |
(Requires Acrobat Reader) 
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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.
|
| Avelox Tablets |
| |
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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Schering Laboratories Patient Assistance Program
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PO Box 6842
Somerset, NJ 08875
Phone
:
800-656-9485
Ext OPT2
Fax:
Not Applicable
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Eligibility
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The patient must have no prescription coverage for any medications and have an income at or below 200% of the Federal Poverty Level. This is a hospital replacement program, so the patient must have already received the medication.The patient must also be a US resident. |
| Who Can Apply
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Someone from the hospital must call for an application. |
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Required
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The hospital contact person must fill out and sign the application.The patient must provide information (financial, insurance, and medical) but no signature is required. |
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Supply
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Ship To
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Hospital |
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Note
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Someone from the hospital must call for an application. |
| |
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.
|
| Avelox Tablets |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form Application Form |
| (Requires Acrobat Reader)
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SP-Cares
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PO Box 52122
Phoenix, AZ 85072
Phone
:
800-656-9485
Ext OPT 1
Fax:
800-995-9620
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Eligibility
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The patient must have no prescription coverage for the requested medication and have an income at or below 250% of the Federal Poverty Level. |
| Who Can Apply
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Anyone requesting assistance can call to request a faxed application or download it from the website. |
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Required
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The doctor must fill out a section and sign the application.The patient must fill out a section, sign the application and attach proof of income. |
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Supply
|
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Up to a 90-day supply |
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Ship To
|
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Doctor's office |
|
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.
|
| Avelox Tablets |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form Application Form |
| (Requires Acrobat Reader)
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