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For additional applications or assistance, please call 80.

Your medication will be sent to your home address unless otherwise requested by the physician/prescriber in Section 3 of the application.

Your physician/prescriber does not need to write your prescription on a separate prescription form.

Incomplete or incorrectly completed applications will be returned.

Under certain circumstances, enrollment may be limited to a calendar year.

Each application is valid for up to 12 months after 12 months a new application will be required.

Each prescription may not exceed a 90-day supply at a time, with a maximum of 3 refills.

A single application may include prescriptions for up to 3 Merck medicines.

Have your physician/prescriber write your prescription(s) in Section 2 of the application. Both the physician/prescriber and the patient MUST sign the application. Take the completed application to your physician/prescriber.

You may print out the form and fill it out by hand using a black ballpoint pen.

You may fill in the fields online and print it.

After downloading the application or receiving your packet in the mail, follow these simple steps to submit your enrollment form for your free Merck medicines:Ĭomplete ALL information on the enrollment form. If you believe that you meet the eligibility criteria for the Merck Patient Assistance Program and you have received a prescription for a Merck product, call toll-freeĨ0 8 AM to 8 PM ET to obtain a brochure outlining the program and an enrollment application, or proceed to Step 4 to download an enrollment form. † For income limits in Alaska and Hawaii, please call 1-80. Residents of the United States, including US Territories, are also eligible. If you do not meet the prescription drug coverage criteria, your income meets the program criteria, and there are special circumstances of financial and medical hardship that apply to your situation, you can request that an exception be made for you.

$73,240 or less for couples, or $111,000 or less for a family of 4. You may qualify for the program if you have a household income of $54,360 or less for individuals, You cannot afford to pay for your medicine. Some examples of other insurance coverage include private insurance, HMOs, Medicaid, Medicare, state pharmacy assistance programs, veterans assistance, or any other social service agency support. You do not have insurance or other coverage for your prescription medicine.

You are a US resident and have a prescription for a Merck product from a health care provider licensed in the United States.* If you have been prescribed a Merck medicine, you may be eligible for the program if all 3 of the following conditions apply: