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

Merck Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: Merck Patient Assistance, Inc.

PO Box 690
Horsham, PA 19044-9979

TEL: 800-727-5400


Languages Spoken:

English, Spanish

Program Website

 

Patient Assistance Applications

Merck Patient Assistance Program Enrollment Form

Merck Patient Assistance Program Enrollment Form (Spanish)

 

Brand Name Medications Covered

 
  • Asmanex HFA aerosol; inhalation
  • Lotrisone
  • Asmanex Twisthaler powder; inhalation
  • Maxalt tablet
  • Belsomra
  • Maxalt-MLT tablet; orally disintegrating
  • Crixivan
  • Nasonex spray; nasal
  • Dificid
  • Proventil HFA aerosol; inhalation
  • Dulera aerosol; inhalation
  • Singulair granule; oral
  • Elocon
  • Sivextro
  • Emend capsule
  • Stromectol tablet
  • Intron A
  • Sylatron
  • Isentress
  • Temodar capsule
  • Isentress HD tablet
  • Trusopt ophthalmic solution/drops
  • Janumet tablet
  • Vytorin tablet
  • Janumet XR tablet; extended release
  • Zetia tablet
  • Januvia tablet
  • Zolinza
 

Generic Name

 
  • albuterol sulfate aerosol; inhalation
  • mometasone furoate aerosol; inhalation
  • aprepitant capsule
  • mometasone furoate monohydrate spray; nasal
  • clotrimazole/betamethasone
  • mometasone furoate powder; inhalation
  • dorzolamide ophthalmic solution/drops
  • montelukast sodium granule; oral
  • ezetimibe tablet
  • peginterferon alfa-2b
  • ezetimibe/simvastatin tablet
  • raltegravir
  • fidaxomicin
  • raltegravir tablet
  • formoterol fumarate/mometasone furoate aerosol; inhalation
  • rizatriptan benzoate tablet
  • indinavir sulfate
  • rizatriptan benzoate tablet; orally disintegrating
  • interferon alfa-2b
  • sitagliptin tablet
  • ivermectin tablet
  • suvorexant
  • metformin/sitagliptin tablet
  • tedizolid
  • metformin/sitagliptin tablet; extended release
  • temozolomide capsule
  • mometasone furoate
  • vorinostat
 

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 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.


Updated September 28, 2018