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Program Details

MERCK & COMPANY, INC.
The Merck Patient Assistance Program

Proventil HFA Inhaler (albuterol)
 
CONTACT INFO
Address: PO Box 690
Horsham, PA 19044-9979
Phone: 1-800-727-5400 Provider Phone: 1-800-496-1365
Fax: Website: The Merck Patient Assistance Program
ELIGIBILITY
Eligibility Info:
  • The program is for patients who do not have pharmaceutical insurance coverage and can not afford to pay for their medicine.
  • Patients are eligible if there is medical and financial need as identified by their physician and they are unable to get help from any other insurers, including private insurance, Medicare, Medicaid, HMOs, state pharmacy assistance programs, Veterans' assistance programs, or any other social service agencies.
  • If you do not meet the income or prescription drug coverage criteria, your income is below a set upper limit, 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.
  • Medicare Part D patients might be eligible but must go through an appeals process once denied.
  • Income at or below: Single 400 % FPL
      Couple 400 % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: None
    Physician License #
    Required:
    State
    Prescriber Signature
    Allowed:
    Physician
    PA
    Application may be
    faxed:
    No
    Eligibility determination
    letter sent:
    Not Published
    MEDICATION
    Receives: Medication
    Shipped To: Provider
    Quantity in Shipment: 90 days
    Delivery Time: 0-1 week
    Re-application Policy: New application every 12 months
    Refill Policy: 3 refills
    If physician requests refills, then the patient can order refills by calling 1-800-496-1365. Patients will receive instructions on the refill process with their initial prescription.
    Other Information:
  • Up to three products can be requested on one enrollment form. Vaccines and injectibles are not included; however, requests for anti-cancer injectibles are accepted.
  • Applications are reviewed on a case-by-case basis.
  • Special Note from Merck: Access to medicines distributed through the Merck Patient Assistance Program is 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.
  • Last Updated: 01/30/2013

     

     

     


    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.


    DocumentForm (English)


    Document Form (Spanish)


    Document Instructions (English)



     

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