Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 2.
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Updated October 13, 2014
 

Dulera

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Merck Patient Assistance Program

This program provides brand name medications at no or low cost.

Provided by: Merck & Company, Inc.

PO Box 690
Horsham, PA 19044-9979

TEL: 800-727-5400


ALT PHONE:
FAX:
Languages Spoken:

English, Spanish

Program Website

 

Patient Assistance Applications

Merck Patient Assistance Program Enrollment Form

Merck Patient Assistance Program Enrollment Form (Spanish)

Merck Patient Assistance Program Enrollment Form Instruction Letter (Spanish)

 

Medications

  • Dulera Aerosol; Inhalation 100mcg/5mcg, 200mcg/5mcg (mometasone furoate/formoterol fumarate dihydrate)
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Yes
Income At or below 400% of FPL
Diagnosis/Medical Criteria Not specified
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Sent to doctor or patient
Returning Mail
Doctor's Action Complete section and sign
Applicant's Action Complete section and sign
Decision Communicated Call for decision
Decision Timeframe Up to 10 business days
   

Medication

Amount/Supply 90 day supply with up to 3 refills, for a total of up to 1 year of medications
Sent To Doctor's office or patient's home
Delivery Time Not specified
Refill Process Patient requests refills via a toll-free number
Limit Not specified
Re-application New application yearly
   

Additional Information

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.


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 2. Updated October 17, 2014
 

Dulera

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Patient Access Network Foundation (PAN)

This is a copay assistance program.

Provided by: Patient Access Network Foundation

PO Box 221858
Charlotte, NC 28222-1858

TEL: 866-316-7263


ALT PHONE:
FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Patient Assistance Applications

PAN Brochure

PAN Eligibility Criteria and Benefit Cap Information

PAN Proof of Expenditure Form

 

Medications

  • Dulera Aerosol; Inhalation dosage varies (formoterol fumarate/mometasone furoate)
 

Eligibility Requirements   

Insurance Status Must have insurance
Those with Part D Eligible? Determined case by case
Income At or below 500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Fax, mail or submit online
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Complete section and sign
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved; shipped same day
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months
   

Additional Information

Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.