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ACT Program
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ACT Program
PO Box 18979
Louisville, KY 40261
Phone
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866-363-6379
Fax:
866-363-6389
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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 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
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Anyone interested can call or download an application and it will be faxed, emailed or mailed to them. |
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Required
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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. |
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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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Patients in need who appear not to qualify should still call. |
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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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| Noxafil tablet; delayed release |
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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 |
(Requires Acrobat Reader) 
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Merck Connect
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,
Phone
:
800-489-5119
Fax:
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Eligibility
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This program is for healthcare professionals only. Patient eligibility will be determined on a case by case basis. Income requirements for this program have not been disclosed. The medication must be medically necessary as determined by a doctor. The patient must be treated by a US licensed healthcare professional. |
| Who Can Apply
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Patients can enroll online. |
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Required
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Doctors must enroll in the program. Patients must inform their doctor that they are in need. |
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Supply
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Up to a 30 day supply. |
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Ship To
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Not specified |
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Note
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Resources for HEALTHCARE PROFESSIONALS ONLY.
The Physician must register to access tools and materials for patient support, product sample requests, up-to-date professional resources, and other Merck professional sites. |
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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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| Noxafil tablet; delayed release |
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