Apply to Merck Patient Assistance Program

Merck gives certain Merck medicines free to people with limited income who have no prescription coverage. Your answers stay in this browser; we never see them.

Who can apply?

Yearly household income before taxes, 2026 limits
Household1 person2 people3 people4 people
Yearly income up to$63,840$86,560$109,280$132,000

Published as $63,840 for one person, $86,560 for two and $132,000 for four (400% of the poverty level). Alaska and Hawaii: call.

For people with no prescription coverage: Medicare, Medicaid, private insurance and veterans' benefits all count as coverage. Someone with coverage whose income qualifies can ask for an exception for special financial and medical hardship.

Not for people whose employer or plan sends them to the program as a condition of coverage.

Your answers

Check each one. Signatures, dates and consent boxes stay blank for you to do by hand.

Medicine
Name and strength, e.g. Trulicity 1.5 mg. Goes on the note for your prescriber; they write the prescription.
You
Two letters, e.g. FL
10 digits
Household
Wages, Social Security, pensions, disability and any other income. 0 if none.
How should the program check income? (optional)
Coverage
Is this your first time applying to this program? (optional)
Which health coverage do you have?
Only Merck's form asks; you can also write it in by hand.
Delivery
Where should the medicine go? (optional)

Then what?

  1. Sign

    • Consent to process information (enrollment page 1: check "I consent")
    • Authorization for health information (enrollment page 2)
    • Applicant declarations (enrollment page 3)
    • Income check by consumer report (enrollment page 3), only if you choose that instead of sending a document

  2. Attach

    • One proof of household income (tax return, a month of pay stubs, or a Social Security, pension, disability, unemployment or veteran benefits letter), unless you choose the consumer-report check

  3. Your prescriber

    • Completes, signs and dates the prescriber section and writes the prescription (section 4)

  4. Send

    • Fax 1-800-498-5540 (Januvia and Janumet: fax 1-800-419-8371. All other medicines: 1-800-498-5540. Don't include the cover page.)
    • Mail to Merck Patient Assistance Program, PO Box 1206, Wilkes Barre, PA 18703-1206

Rather apply online? Apply on the Merck Patient Assistance Program site.

Questions: call Merck Patient Assistance Program at 1-800-727-5400. Up to 1 year.

Free. Applying to Merck PAP is free. EveryCard Rx isn't paid by the program and never sends anything for you. Form US-NON-22610 8/26, rules checked 2026-11-06 from the program's own pages. Something out of date? Tell us.