Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 5.
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Heron Connect

This program provides brand name medications at no or low cost

Provided by: Heron Therapeutics, Inc.


TEL: 844-437-6611


FAX: 844-504-8652
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

Heron Connect Insurance Verification and Program Enrollment Form (Cinvanti)(Sustol)

Heron Connect Insurance Verification and Program Enrollment Form (Zynrelef)

 

Medications

  • aprepitant injectable emulsion; iv (Cinvanti) Injectable emulsion; IV
 

Eligibility Requirements   

Insurance Status Contact program for details.
Those with Part D Eligible? Contact program for details.
Income Determined case by case
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Must be residing in the US or US territory
   

Application

Obtaining Call or download
Receiving Faxed or downloaded from website
Returning Fax
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Doctor notified
Decision Timeframe 2-3 business days
   

Medication

Amount/Supply Not specified
Sent To Doctor's office
Delivery Time Not specified
Refill Process Not specified
Limit One year
Re-application New enrollment every 12 months
   

Additional Information

Co-payment assistance, reimbursement support, and patient assistance programs are available for eligible patients.

Updated September 17, 2021


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 5.
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Merck Access Program for Emend

This program provides brand name medications at no or low cost

Provided by: Merck Patient Assistance Program, Inc.

Merck Access Program
PO Box 29067
Phoenix, AZ 85038

TEL: 855-257-3932


FAX: 855-755-0518
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Merck Access Program Enrollment Form for Emend

 

Medications

  • aprepitant oral suspension (Emend) Oral Suspension
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Contact program for details.
Income Not disclosed
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must be residing in the US or a US territory, and under the care of a US physician
   

Application

Obtaining Call, download or apply online
Receiving Complete online, download from website or faxed.
Returning Fax or submit online
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient and Doctor are notified
Decision Timeframe Not specified
   

Medication

Amount/Supply Not specified
Sent To Not specified
Delivery Time Not specified
Refill Process Patient must contact company
Limit Not specified
Re-application New application yearly
   

Additional Information

Patient must sign the enrollment form to give the program permission to access their financial information in order to determine eligibility.

Patients in need who appear not to qualify should still call.

Updated September 08, 2021


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 5.
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Merck Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: Merck Patient Assistance Program, Inc.

PO Box 690
Horsham, PA 19044-9979

TEL: 800-727-5400


Languages Spoken:

English, Spanish

Program Website

 

Program Applications and Forms

Merck Patient Assistance Program Enrollment Form

Merck Patient Assistance Program Enrollment Form (Spanish)

Merck Patient Assistance Program Brochure

Merck Access and Patient Assistance (COVID-19) Information: Contact program

HIV Common Application: Merck Patient Assistance Program

 

Medications

  • aprepitant capsule (Emend) Capsule
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Contact program for details.
Income At or below 400% of FPL
Diagnosis/Medical Criteria Not specified
US Residency Required? Must be residing in the US or a US territory, and under the care of a US physician
   

Application

Obtaining Call or download
Receiving Sent to doctor or patient
Returning Mail original application. Do not fax
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.

*The Enrollment Form must be mailed. Please do not fax.

Call for most recent medications as the list is subject to change.

Updated September 08, 2021


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 4 of 5.
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Patient Access Network Foundation (PAN)

This is a copay assistance program

Provided by: Patient Access Network Foundation


TEL: 866-316-7263


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Patient Access Network Foundation (PAN) Application: Contact program

 

Medications

  • aprepitant (Emend) 
  • aprepitant injectable emulsion; iv (Cinvanti) Injectable emulsion; IV
 

Eligibility Requirements   

Insurance Status *See Additional Information section below
Those with Part D Eligible? Determined case by case
Income Between 400-500% of FPL
Diagnosis/Medical Criteria FDA Approved Diagnosis - See Program Website for Details
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Complete online or by phone
Returning Complete online or by phone
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Call for information or inform doctor that he/she is in need
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

*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.

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.

Note: All new enrollment is now done electronically or over the phone. Contact program for details.

Updated September 27, 2021


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 5 of 5.
 

HarborPath ADAP Waiting List Program

For Healthcare Professionals Only

Provided by: HarborPath, Inc.


TEL: 855-300-8916


FAX: 888-237-9831
Languages Spoken:

English

Program Website

 

Program Applications and Forms

HarborPath ADAP Waiting List Program Enrollment Form

 

Medications

  • aprepitant (Emend) 
 

Eligibility Requirements   

Insurance Status Must be uninsured
Those with Part D Eligible? No
Income Determined case by case
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Faxed or downloaded from website
Returning Fax from Doctor's office
Doctor's Action Enroll in program, complete form and obtain patient consent
Applicant's Action Inform Doctor that he/she is in need
Decision Communicated Doctor notified
Decision Timeframe Within 24-48 hours
   

Medication

Amount/Supply Varies
Sent To Patient's home, unless otherwise noted
Delivery Time Within 48 hours
Refill Process Doctor/Doctor's office must contact the Program
Limit Varies
Re-application New prescription required
   

Additional Information

Resources for HEALTHCARE PROFESSIONALS ONLY.

Patients are eligible for the HarborPath ADAP Waiting List Program if they: Meet eligibility for the ADAP Waiting List Program in their state of residency; and have a confirmation letter from their state ADAP indicating patient is on the ADAP waiting list.

Typical eligibility requirements do not apply to the ADAP Waiting List Program.

Updated September 13, 2021