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Patient Assistance Information

 
2 Programs for Maxalt Tablets
 
 
Merck Patient Assistance Program

PO Box 690
Horsham, PA 19044-9979
Phone : 800-727-5400
Fax: n/a
Eligibility
> The patient must have no prescription coverage for the requested medication and have an income at or below 200% of the Federal Poverty Level. The patient must also be a US resident. Anyone in need should apply because they do make exceptions for people truly in need. The upper limit for exceptions is 400% of the Federal Poverty Level.
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
> Up to a 90-day supply
Ship To
> Either Doctor's office or Patient's home
Note
> The patient or doctor must contact the company for refills. Every year a new application is needed.
 
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 Application Form
Download printable Form Application Form - Spanish
(Requires Acrobat Reader
 
 
Merck Prescription Discount Program

Merck Prescription Discount Program
PO Box 369
Horsham, PA 19044-9945
Phone : 800-506-3725
Fax:
Eligibility
> The patient must have no prescription insurance. The patient must also be a US resident with a prescription from a US doctor.
Who Can Apply
> The patient can call to get an application, apply on line, or download the application.
Required
> The doctor needs to provide a prescription to the patient.The patient must fill out a section and sign the application.
Supply
>
Ship To
> Patient's home
Note
> The patient can call to get an application, apply on line, or download the 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.
 
Maxalt Tablets
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
Download printable Form Spanish Version
(Requires Acrobat Reader