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Patient Assistance Information

1 Program for Maxalt Tablets
Merck Patient Assistance Program

PO Box 690
Horsham, PA 19044
Phone : 800-727-5400
> 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
> Anyone interested can call or download the application.
> Doctors and patients must complete and sign the application. The original application must be mailed NOT faxed. A new application is needed yearly.
> 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.
Ship To
> Doctor's office or patient's home
> 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.
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.
Maxalt Tablets
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form
Download printable Form
(Requires Acrobat Reader