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.
Biktarvy copay card download#
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:
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