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Patient Assistance Information

 
 
 
AccessSivextro Program


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Phone : 844-282-4782
Fax: 844-282-4783
Eligibility
> This program is for healthcare providers only. Patients must be uninsured. Patients with Medicare Part D are not eligible. The medication must be medically necessary as determined by a doctor. Income requirements have not been disclosed for this program. Patients must be a US resident.
Who Can Apply
> Doctors or the doctors office must call to have the application faxed or mailed or they can download the application.
Required
> Doctor's must complete, sign the application and attach required documents. Patients must complete their section and sign.
Supply
> Not specified
Ship To
> Not specified
Note
> This program is intended for US HEALTHCARE PROFESSIONALS and/or Professionals involved in Healthcare Reimbursement ONLY. This program also provides copay assistance for patients with commercial insurance. Merck Product Replacement Program: 1-866-363-6379
 
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.
 
Sivextro tablet
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader