Program Applications

Tips for using the applications:

  • You will need Adobe Reader to open the applications. Download this free program or the latest version, which is recommended.
  • Click the button in the top right of the application to turn on the Highlight Fields Option which will highlight the fields to be filled out.
  • Use the "tab" key to easily go to the next field.

As of 07/07/2015 there are 622 applications available.

Click on the first letter of the name of the program. Then click on the application for that program. Dates next to each listing reflect the last update. Some applications may need to be opened with a different viewer depending on which browser you are using. Firefox users may get a message saying "This PDF document might not be displayed correctly." Try clicking on the "Open With Different Viewer" option. If you are still unable to interactively complete the application, use a different browser.

Send the completed application to the address on the application and not to NeedyMeds.

If you cannot find an application or are having trouble printing one, contact the program or company.

Contact NeedyMeds if you find any content errors.

For link problems or other technical problems, send an email to webmaster.

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Cetylite Free Sample Program: Contact program - (This program is currently not accepting new applications)
Generic Assistance Program (GAP) Application - (This program is currently not accepting new applications)
Makena Prescription Form 05/01/15
Marplan Patient Assistance Program Enrollment Form 03/16/15
MatriStem Prior Authorization & Insurance Verification Form 04/16/15
Matulane Patient Assistance Program: Contact program
Meda Pharamaceuticals Patient Assistance Program Application 05/11/15
MedImmune Assistance Program (MAP) Application 05/29/15
MedImmune Assistance Program (MAP) Application (Spanish) 05/29/15
MedImmune Assistance Program (MAP) Patient Authorization Form 05/29/15
MedImmune Assistance Program (MAP) Patient Authorization Form (Spanish) 09/24/14
MedImmune Copay Savings Program (Synagis): Contact program
Merck Access Program Enrollment Form 04/16/15
Merck Access Program Enrollment Form for Keytruda 06/18/15
Merck Access Program Product Replacement Request Form for Keytruda 06/18/15
Merck Connect Registration Form: Contact program
Merck PAP Application for Invanz, Primaxin, and Cancidas 04/06/15
Merck Patient Assistance Program Enrollment Form 06/09/15
Merck Patient Assistance Program Enrollment Form (Spanish) 06/09/15
Merck Patient Assistance Program Enrollment Form Instruction Letter (Spanish) 06/09/15
Merck Vaccine Patient Assistance Program Application 06/09/15
Merck Vaccine Patient Assistance Program Application (Spanish) 06/09/15
Millennium Reimbursement Assistance for Velcade Enrollment Form 07/06/15
Mission Pharmaceutical Patient Assistance Program: Contact program
Mission Product Request: Contact program
MS Lifelines Enrollment Form: Contact program
MS One to One Start Form 05/05/15
MuGard Prescription Form 03/20/15
Musella Co-payment Assistance Application 05/13/15
My Brisdelle Reimbursement Form 04/16/15
My PN Support Program Application 05/01/15
MyAlprolix Free Trial Plus Program Enrollment Form 04/13/15
MyAlprolix Program Enrollment Form 04/13/15
MyAlprolix Program Enrollment Form (Spanish) 04/13/15
MyEloctate Free Trial Plus Program Enrollment Form 04/13/15
MyEloctate Program Enrollment Form 04/13/15
Mylan Clozapine Patient Assistance Program Application 09/24/14
Mylan EMSAM Transdermal System Patient Assistance Program Application 09/23/14
Mylan EpiPen 2-Pak Auto-Injector Patient Assistance Program Application 09/23/14
Myobloc PAP Enrollment Form 06/26/15
Myobloc Reimbursement Enrollment Form 06/26/15

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