If you believe that you meet the guidelines for the Merck Patient Assistance Program and you have received a prescription for a Merck medicine, call toll-free 1-800-727-5400 8:00 AM–8:00 PM ET to obtain a brochure outlining the program and an enrollment application or click here to request a brochure and application online or download the application directly. After downloading the application or receiving your packet in the mail, follow these simple steps to submit your application for your free Merck medicines:
1. Complete ALL information on the application form.
You may fill in the fields online and print it.
OR
You may print out the form and fill it out by hand using a black ballpoint pen.
2. Take the completed application to your physician/prescriber. Both the physician/prescriber and the patient MUST sign the application.
3. Have your physician/prescriber write your prescription(s) in Section 2 of the application.
A single application may include prescriptions for up to 3 Merck drugs.
Each prescription may not exceed a 90-day supply at a time, with a maximum of 3 refills.
Each application is valid for up to 12 months; after 12 months a new application will be required. Under certain circumstances, enrollment may be limited to a calendar year.
A separate Merck Patient Assistance Program application is REQUIRED for each patient.
4. Mail completed applications to:
Merck Patient Assistance Program
PO Box 690
Horsham, PA 19044-9979
Please Note:
Incomplete or incorrectly completed applications will be returned.
Section 2 is your prescription. There is no need to write your prescription on a separate prescription form.
Patient's prescription will be sent to the patient's home address unless otherwise requested by the physician/prescriber in Section 3 of the application.
For additional applications or assistance, please call 1-800-727-5400.
Other Important Information
Please discuss the risks and benefits of all medicines with your doctor and take only as prescribed by your doctor.
Medicines distributed through the Merck Patient Assistance Program are free of charge to all eligible patients. Merck is not associated with any individuals or organizations that may charge patients a fee(s) to assist them in completing applications for our program. These individuals or organizations are acting independently of Merck & Co., Inc., and do not have Merck's consent.
Merck reserves the right to change or discontinue the program at any time.
