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Program Details
MERCK & COMPANY, INC.
Merck Vaccine Patient Assistance Program
Vaqta
(Hepatitis A vaccine, inactivated)
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| ELIGIBILITY
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| Eligibility
Info: |
Patient must be a US resident and be at least 19 years old.
Patient must not have health insurance coverage. However, individuals who don't meet the insurance criteria may still qualify for the Merck Patient Assistance Program if they attest that they have special circumstances of financial and medical hardship, and their income meets the program criteria. |
| Income at or below: |
Single |
|
400
% FPL |
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Couple |
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400
% FPL |
| Federal Poverty Level Calculator |
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| Medical expenses
can be deducted from reported income: |
Not
Published |
| Social security requested on form: |
No |
| US citizenship/residency specified:
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Yes |
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APPLICATION |
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| Attachments
Required: |
None
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Physician
License #
Required: |
State
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Prescriber
Signature
Allowed: |
Physician
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Application
may be
faxed: |
Yes |
Eligibility
determination
letter sent: |
Determination is made within 10 - 15 minutes within receipt of faxed application.
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| MEDICATION |
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| Receives: |
Medication
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| Shipped To: |
Provider
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| Quantity in
Shipment: |
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| Delivery Time: |
0-1 week
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| Re-application
Policy: |
A new application will need to be completed and submitted to the Merck Vaccine Patient Assistance Program for eligibility assessment prior to a patient receiving a subsequent dose in a multi-dose series or for another Merck vaccine.
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| Refill Policy: |
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| Other Information: |
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Last Updated: 04/04/2024
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Application Forms
& Instructions
The following documents
are provided in interactive PDF format, allowing you to type information
directly into the form.
 Form (English)
Form (Spanish)
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