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Patient Assistance Information

Merck Access Program

PO Box 29067
Phoenix, AZ 85038
Phone : 855-257-3932
Fax: 855-755-0518
> This program provides brand name medications at no or low cost to patients that are uninsured or underinsured. Medicare Part D recipients are not eligible. Patients must be 500% below the federal poverty level. A diagnosis code must be provided and the patient must be treated by a US doctor.
Who Can Apply
> Anyone interested can call or download the application.
> Doctors must complete, sign and attach a prescription. Patients must also complete and sign. Application can then be faxed or mailed.
> Up to 30 day supply
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.
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.
Emend injection
Intron A vial
Sylatron syringe
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form
(Requires Acrobat Reader