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Program Details

MERCK & COMPANY, INC.
Merck Co-Pay Assistance Program

Temodar (temozolomide)
 
CONTACT INFO
Address:
,
Phone: 1-855-263-1774 Provider Phone:
Fax: 1-866-254-9411 Website:
ELIGIBILITY
Eligibility Info:
  • Patient must not have public insurance, but may have private insurance.
  • Patients with Medicare Part D are not eligible.
  • MA residents are not eligible.
  • Income at or below: Single 500 % FPL
      Couple 500 % 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: Insurance information
    Physician License #
    Required:
    NPI
    Prescriber Signature
    Allowed:
    Not required
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    MEDICATION
    Receives:
    Shipped To:
    Quantity in Shipment: Not Published
    Delivery Time: Not Published
    Re-application Policy: New application every 12 months
    Refill Policy:
    Other Information:

    Last Updated: 07/07/2014

     

     

     


    Application Forms
    & Instructions

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



     

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