![]() The Physician must register to access tools and materials for patient support, product sample requests, up-to-date professional resources, and other Merck professional sites. Must be treated by US licensed healthcare provider Medically Necessary as determined by a Doctor Merck Connect Product Information: Contact program Merck Connect For Healthcare Professionals Only Typical eligibility requirements do not apply to the ADAP Waiting List Program. 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. ![]() Resources for HEALTHCARE PROFESSIONALS ONLY. Medically appropriate condition/diagnosisĮnroll in program, complete form and obtain patient consentĭoctor/Doctor's office must contact the Program HarborPath ADAP Waiting List Program Enrollment Form HarborPath ADAP Waiting List Program For Healthcare Professionals Only Note: All new enrollment is now done electronically or over the phone. *Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.Ĭall 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. Patient presents voucher/card to pharmacy for each refill Patient is sent savings card to be used at pharmacy Merck Access Program Insurance coverage for patients Co-pay assistance for eligible patients Referral to the Merck Patient Assistance Program for eligibility. *See Additional Information section belowįDA Approved Diagnosis - See Program Website for DetailsĬall for information or inform doctor that he/she is in need Patient Access Network Foundation (PAN) Application: Contact program Provided by: Patient Access Network FoundationĮnglish, Spanish, Others By Translation Service Patient Access Network Foundation (PAN) This is a copay assistance program Please do not fax.Ĭall for most recent medications as the list is subject to change. 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. Patient requests refills via a toll-free numberĪt Merck we realize that sometimes exceptions need to be made based on the patient's individual circumstances. Save up to 150 per prescription on JANUMET XR or JANUMET with a coupon from your doctor. Must be residing in the US or a US territory, and under the care of a US physicianĬomplete section, sign, attach required documents HIV Common Application: Merck Patient Assistance Program Merck Patient Assistance Program Brochure Merck Patient Assistance Program Enrollment Form (Spanish) savings card available for Trulicity (dulaglutide) Search Trulicity (type. Merck Patient Assistance Program Enrollment Form Maximum total savings is 2000 over 12 months. Provided by: Merck Patient Assistance Program, Inc. Merck Patient Assistance Program This program provides brand name medications at no or low cost
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