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value="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" /> </div>  <div class="hero-container"> <div class="container"> <h1>The Merck Patient Assistance Program Helps Those in Need</h1> <img id="herocontainer_holder_imgHero" class="img-responsive" src="images/inside-hero-img_MPAP.jpg" /> </div>  </div> <div class="container main-content-container"> <div class="row"> <div id="print"> <div id="main-content" class="col-lg-12 col-md-12 col-sm-12 main-content"> <div class="row"> <div class="col-lg-9 col-md-9 col-sm-8"> <h2><strong> LAGEVRIO™</strong> </h2> <p class="genericName"> (molnupiravir)  200 mg capsules [Use Expedited Request] </p> <p> This private and confidential program provides product free of charge to eligible individuals, primarily the uninsured who, without our assistance, could not afford needed Merck medicines. Individuals who don't meet the insurance criteria may still qualify for this program if they attest that they have special circumstances of financial and medical hardship, and their income meets the program criteria. A single application may provide for up to 1 year of product free of charge to eligible individuals and an individual may reapply as many times as needed.<br /><br /> <p><strong>LAGEVRIO</strong> has not been approved, but has been authorized for emergency use by the US Food and Drug Administration (FDA) under an Emergency Use Authorization (EUA). Please refer to the <a href="https://www.fda.gov/drugs/emergency-preparedness-drugs/emergency-use-authorizations-drugs-and-non-vaccine-biological-products" target="_blank">EUA and authorized labeling</a> for information on the authorized use of the product. The emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of the emergency use of drugs and biological products during the COVID-19 pandemic under Section 564(b)(1) of the Act, 21 U.S.C. § 360bbb-3(b)(1), unless the declaration is terminated or authorization revoked sooner.</p><br/> <p>Overnight Deliveries for expedited requests are subject to exceptions, including but not limited to: requests received after 5 PM ET Monday through Friday, or after 1 PM ET on Saturdays. Next day delivery is not available on Sundays or holidays and may not be available in certain areas.</p> </p> <p> <span id="maincontent_holder_lblMessage" class="alert-red"></span> </p> <p> </p> </div> <div class="col-lg-3 col-md-9 col-sm-4 sideBar"> <h4><a href='/programs.aspx'>Read more about the Merck<br />Patient Assistance Programs</a></h4><br /><h4>Program Contact Information</h4> <div class="media"> <div class="media-left media-middle"> <a href="#"> <img class="media-object" src="/images/phone.jpg" alt="..." style=" width: 30px;"> </a> </div> <div class="media-body"> <p class="media-heading">800-727-5400</p><br /> <p><strong>EXPEDITED REQUEST ONLY</strong>, please call <nobr>800-727-5400</nobr>, and a program representative will help you.</p> </div> </div> <div class="media"> <div class="media-left media-middle"> <a href="#"> <img class="media-object" src="/images/clock.jpg" alt="..." style=" width: 30px;"> </a> </div> <div class="media-body"> <p class="media-heading"> Hours: <nobr><nobr>8 AM – 8 PM ET</nobr></nobr> <br>Days: Monday – Friday <br/>Saturdays 8 AM - 1 PM ET <br/>No hours available on Sundays or Holidays </p> </div> </div> <br /><br /> </div> </div>  <ul class="nav nav-tabs responsive" id="myTab"> <li class="active"><a href="#qualify" onclick="javascript:trackTabView(''); return false;"><span class="number">1</span> Who May Qualify</a></li> <li><a href="#eligibility" onclick="javascript:trackTabView('#Check Your Eligibility'); return false;"><span class="number">2</span> Check Your Eligibility</a></li> <li><a href="#started" onclick="javascript:trackTabView('#How to Get Started'); return false;"><span class="number">3</span> How to Get Started</a></li> <li><a href="#enrollment" onclick="javascript:trackTabView('#Download Enrollment Form'); return false;"><span class="number">4</span> Begin Enrollment </a></li> </ul> <div class="tab-content responsive"> <h3 class="whomayqualify">Who May Qualify</h3> <div class="tab-pane active" id="qualify"> <p>If you have been prescribed a Merck medicine, you may be eligible for the program if all 3 of the following conditions apply: </p> <ol style="list-style-type: none;"> <li class="one"> <p>You are a US resident and have a prescription for a Merck product from a health care provider licensed in the United States.<sup>(1)</sup></p> <p class="bold">AND</p> </li> <li class="two"> <p>You do <em>not</em> have insurance or other coverage for your prescription 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.<sup>(2)</sup></p> <p class="bold">AND</p> </li> <li class="three"> <p>You cannot afford to pay for your medicine. You may qualify for the program if you have a household income of $62,600 or less for individuals, $84,600 or less for couples, or $128,600 or less for a family of 4.<sup>(3)</sup></p> </li> </ol> <br /> <p><sup>(1)</sup> You do not have to be a US citizen. Residents of the United States, including US Territories, are also eligible.</p> <p><sup>(2)</sup> If you do not meet the insurance 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. Patients may not have an insurance plan or employer that participates in or are involved in any way with an alternative funding program that requires or encourages you to apply to the Merck Patient Assistance Program as a condition, requirement, or prerequisite for coverage of specific Merck medications.</p> <p><sup>(3)</sup> For income limits in Alaska and Hawaii, please call 1-800-727-5400.</p> </div> <h3 class="howtogetstarted">How to Get Started</h3> <div class="tab-pane" id="started"> <p><strong>This product is ONLY available through an EXPEDITED request. Please call 800-727-5400 and tell the program representative that you are making an Expedited request for LAGEVRIO. Please note, program representatives are available Monday through Friday from 8 AM to 8 PM ET, and on Saturday from 8 AM to 1 PM ET. Representatives are not available on Sundays or holidays. Follow the program representative’s instructions. <u>Do not</u> mail in your enrollment form.</strong></p> <p>If you believe that you meet the eligibility criteria for the Merck Patient Assistance Program, <strong>call toll-free 800-727-5400</strong> and tell the program representative that you are making an <strong>Expedited</strong> request for <strong>LAGEVRIO</strong>. Then follow the program representative's instructions to submit your request. Please ensure the following:</p> <ol style="list-style-type: none;"> <li class="one"> <p><strong>Complete ALL information on the enrollment form,</strong> and sign in all designated areas.</p> </li> <li class="two"> <p><strong>The physician/prescriber must write the prescription in Section 4 of the enrollment form.</strong></p> <ul> <li>Each enrollment is valid for up to 12 months; after 12 months a new enrollment form will be required. Under certain circumstances, enrollment may be limited to a calendar year. </li> </ul><br /> </li> </ol> <div class="enrollment"> <h4>Please Note:</h4> <p>This product is <strong>available only by Expedited Request</strong>. Please note, program representatives are available Monday through Friday from 8 AM to 8 PM ET, and on Saturday from 8 AM to 1 PM ET. Representatives are not available on Sundays or holidays. You must call 800-727-5400 and a program representative will help you. <strong>Do not mail in your enrollment form.</strong></p> <ul> <li>Incomplete or incorrectly completed enrollment forms will be returned. </li> <li>Section 4 is your prescription. Your physician/prescriber does not need to write your prescription on a separate prescription form. </li> <li>Your medication will be sent to your home address unless otherwise requested by the physician/prescriber in Section 1 of the enrollment form. </li> <li>For additional enrollment forms or assistance, please call 800-727-5400. </li> </ul> <h4>Other Important Information</h4> <p>Please discuss the risks and benefits of all medicines with your health care provider and take only as prescribed by your health care provider.</p> <p>Overnight Deliveries for expedited requests are subject to exceptions, including but not limited to: requests received after 5 pm ET Monday through Friday, or after 1 PM ET on Saturdays. Next day delivery is not available on Sundays or holidays and may not be available in certain areas.</p> </div> </div> <h3 class="checkyoureligibility">Check Your Eligibility</h3> <div class="tab-pane" id="eligibility"> <div class="form-horizontal"> <script type="text/javascript"> //<![CDATA[ Sys.WebForms.PageRequestManager._initialize('ctl00$maincontent_holder$ScriptManager1', 'form1', ['tctl00$maincontent_holder$pnlForm','maincontent_holder_pnlForm'], ['ctl00$maincontent_holder$btnSubmit','maincontent_holder_btnSubmit'], [], 90, 'ctl00'); //]]> </script> <div id="maincontent_holder_pnlForm"> <p>Please answer these short questions to see if you may qualify. You must answer ALL questions on this page to be considered. <br /><em>This information is not collected or retained.</em></p> <div class="form-group form-group-sm"> <label class="col-sm-9 col-xs-6 control-label" for="formGroupInputSmall"> <ol> <li> Do you have (or intend to get) a prescription for this Merck product from a health care provider licensed in the United States? </li> </ol> </label> <div class="col-sm-3 col-xs-6 form-radio "> <span id="maincontent_holder_rblPrescription"><input id="maincontent_holder_rblPrescription_0" type="radio" name="ctl00$maincontent_holder$rblPrescription" value="Y" /><label for="maincontent_holder_rblPrescription_0">Yes</label><input id="maincontent_holder_rblPrescription_1" type="radio" name="ctl00$maincontent_holder$rblPrescription" value="N" /><label for="maincontent_holder_rblPrescription_1">No</label></span>   </div> </div> <div class="form-group form-group-sm"> <label class="col-sm-9 col-xs-6 control-label" for="formGroupInputSmall"> <ol start="2"> <li>Do you have health insurance or other coverage for this prescription product?<br /> (examples include private insurance, HMOs, PPOs, Medicaid, Medicare, college health plans, state pharmacy assistance programs, veterans’ assistance, or any other social service agency support) </li> </ol> </label> <div class="col-sm-3 col-xs-6"> <span id="maincontent_holder_rblInsurance"><input id="maincontent_holder_rblInsurance_0" type="radio" name="ctl00$maincontent_holder$rblInsurance" value="Y" /><label for="maincontent_holder_rblInsurance_0">Yes</label><input id="maincontent_holder_rblInsurance_1" type="radio" name="ctl00$maincontent_holder$rblInsurance" value="N" /><label for="maincontent_holder_rblInsurance_1">No</label></span>   </div> </div> <div class="form-group form-group-sm"> <label class="col-sm-9 col-xs-6 control-label" for="formGroupInputSmall"> <ol start="3"> <li>Do you live in the United States or one of the US Territories?</li> </ol> </label> <div class="col-sm-3 col-xs-6"> <span id="maincontent_holder_rblResidence" onclick="javascript:radioBtnListOnClick('ctl00$maincontent_holder$rblResidence','maincontent_holder_trState');"><input id="maincontent_holder_rblResidence_0" type="radio" name="ctl00$maincontent_holder$rblResidence" value="Y" /><label for="maincontent_holder_rblResidence_0">Yes</label><input id="maincontent_holder_rblResidence_1" type="radio" name="ctl00$maincontent_holder$rblResidence" value="N" /><label for="maincontent_holder_rblResidence_1">No</label></span>   </div> </div> <div id="maincontent_holder_trState" class="form-group form-group-sm" style="display:none;"> <label class="col-sm-9 col-xs-6 control-label" for="formGroupInputSmall"> <ol style="list-style-type:none;"> <li>Select the state/territory you live in</li> </ol> </label> <div class="col-sm-3 col-xs-6"> <select name="ctl00$maincontent_holder$ddlState" id="maincontent_holder_ddlState"> <option value=""></option> <option value="AL">Alabama</option> <option value="AK">Alaska</option> <option value="AS">American Samoa</option> <option value="AZ">Arizona</option> <option value="AR">Arkansas</option> <option value="CA">California</option> <option value="CO">Colorado</option> <option value="CT">Connecticut</option> <option value="US">Continental US</option> <option value="DE">Delaware</option> <option value="DC">District of Columbia</option> <option value="FL">Florida</option> <option value="GA">Georgia</option> <option value="GU">Guam</option> <option value="HI">Hawaii</option> <option value="ID">Idaho</option> <option value="IL">Illinois</option> <option value="IN">Indiana</option> <option value="IA">Iowa</option> <option value="KS">Kansas</option> <option value="KY">Kentucky</option> <option value="LA">Louisiana</option> <option value="ME">Maine</option> <option value="MD">Maryland</option> <option value="MA">Massachusetts</option> <option value="MI">Michigan</option> <option value="MN">Minnesota</option> <option value="MS">Mississippi</option> <option value="MO">Missouri</option> <option value="MT">Montana</option> <option value="NE">Nebraska</option> <option value="NV">Nevada</option> <option value="NH">New Hampshire</option> <option value="NJ">New Jersey</option> <option value="NM">New Mexico</option> <option value="NY">New York</option> <option value="NC">North Carolina</option> <option value="ND">North Dakota</option> <option value="XX">Northern Mariana Islands</option> <option value="OH">Ohio</option> <option value="OK">Oklahoma</option> <option value="OR">Oregon</option> <option value="PA">Pennsylvania</option> <option value="PR">Puerto Rico</option> <option value="RI">Rhode Island</option> <option value="SC">South Carolina</option> <option value="SD">South Dakota</option> <option value="TN">Tennessee</option> <option value="TX">Texas</option> <option value="UT">Utah</option> <option value="VT">Vermont</option> <option value="VI">Virgin Islands</option> <option value="VA">Virginia</option> <option value="WA">Washington</option> <option value="WV">West Virginia</option> <option value="WI">Wisconsin</option> <option value="WY">Wyoming</option> </select>   </div> </div> <div class="form-group form-group-sm"> <label class="col-sm-9 col-xs-6 control-label" for="formGroupInputSmall"> <ol start="4"> <li>How many people are in your household?<br />(including yourself, your spouse, and any dependents)</li> </ol> </label> <div class="col-sm-3 col-xs-6"> <input name="ctl00$maincontent_holder$txtFamilySize" type="text" id="maincontent_holder_txtFamilySize" class="form-control" placeholder="" />     </div> </div> <div class="form-group form-group-sm"> <label class="col-sm-9 col-xs-6 control-label" for="formGroupInputSmall"> <ol start="5"> <li> What is your annual gross household income in US dollars?</li> </ol> </label> <div class="col-sm-3 col-xs-6"> <input name="ctl00$maincontent_holder$txtFamilyIncome" type="text" id="maincontent_holder_txtFamilyIncome" class="form-control" placeholder="" />     </div> </div> <div id="maincontent_holder_trAge" class="form-group form-group-sm" style="display:none;"> <label class="col-sm-9 col-xs-6 control-label" for="formGroupInputSmall"> <ol start="6"> <li> What is your age?</li> </ol> </label> <div class="col-sm-3 col-xs-6"> <input name="ctl00$maincontent_holder$txtAge" type="text" value="1" id="maincontent_holder_txtAge" class="form-control" placeholder="" />     </div> </div> <div id="maincontent_holder_Div1" class="form-group form-group-sm"> <label class="col-sm-9 col-xs-7 control-label" for="formGroupInputSmall"></label> <div class="col-sm-3 col-xs-12"> <input type="submit" name="ctl00$maincontent_holder$btnSubmit" value="Check Eligibility" onclick="javascript:WebForm_DoPostBackWithOptions(new WebForm_PostBackOptions("ctl00$maincontent_holder$btnSubmit", "", true, "", "", false, false))" id="maincontent_holder_btnSubmit" class="btn btn-default " /> <input type="reset" id="btnReset" value="Reset" class="btn btn-default" /> </div> </div> <br /><br /> </div>  </div> </div> <h3 class="howtogetstarted">Download Enrollment Form (Application)</h3> <div class="tab-pane" id="enrollment"> <div id="maincontent_holder_online"> </div> <div class="row" style="padding:20px 0px 20px 20px"> <div class="col-sm-12"> <h2>Enrollment Options</h2> <p> This product is ONLY available through an EXPEDITED request. Please call 800-727-5400 and tell the program representative that you are making an Expedited request for LAGEVRIO. Please note, program representatives are available Monday through Friday from 8 AM to 8 PM ET, and on Saturday from 8 AM to 1 PM ET. Representatives are not available on Sundays or holidays. Follow the program representative's instructions to make your request. <strong><u>Do not</u> mail in your enrollment form.</strong> </p>  </div>         <div class="col-xs-12"> <div class="needAssistanceBox"> <h5>Important Information:</h5> <p> This product is <strong>available only by Expedited Request</strong>. Please note, program representatives are available Monday through Friday from 8 AM to 8 PM ET, and on Saturday from 8 AM to 1 PM ET. Representatives are not available on Sundays or holidays. You must call 800-727-5400 and a program representative will help you. <strong>Do not mail in your enrollment form.</strong> </p> <ul> <li>Incomplete or incorrectly completed enrollment forms (applications) will be returned.</li> <li>Section 4 is your prescription. Your physician/prescriber does not need to write your prescription on a separate prescription form.</li> <li>Your medication will be sent to your home address unless otherwise requested by the physician/prescriber in Section 1 of the application.</li> <li>For additional enrollment forms or assistance, please call 800-727-5400.</li> </ul> <p>Please discuss the risks and benefits of all medicines with your health care provider and take only as prescribed by your health care provider.</p> <p>Overnight Deliveries for expedited requests are subject to exceptions, including but not limited to: requests received after 5 PM ET Monday through Friday, or after 1 PM ET on Saturdays. Next day delivery is not available on Sundays or holidays and may not be available in certain areas.</p> <br /> <h5>Need Assistance?</h5> <ul> <li>For additional help on how to complete Enrollment Application forms, please visit our <a href="/Resources.aspx">resources</a>.</li> <li>You can contact a support representative at <strong class="green-text-color">800-727-5400</strong>, Monday through Friday, from <nobr>8 AM – 8 PM ET</nobr>.</li> </ul> </div> </div> </div> </div> </div>   <div class="modal fade" id="onlineEnrollment" tabindex="-1" role="dialog" aria-labelledby="OnlineEnrollment"> <div class="modal-dialog modal-dialog-centered" role="document"> <div class="modal-content">  <div class="modal-body"> <div class="row" style="padding-left:20px;"> <div class="col-lg-12"> <h4>Please note:</h4> <p>You are now leaving merckhelps.com and going to our partner site to start the online application process.</p> </div></div> <div class="row" style="padding:20px;"> <div class="col-lg-6 modalEnrollment"> <h3>For Patients</h3> <p></p> <a id="maincontent_holder_lnkPatient" class="aspNetDisabled btn btn-primary green-bg-color buttonPanel pt-link" target="_blank">Patient Online Enrollment Unavailable</a> </div> <div class="col-lg-6"> <h3>For Health Care Providers</h3> <p> </p> <a id="maincontent_holder_lnkHCP" class="btn btn-primary green-bg-color buttonPanel hcp-link" href="https://lagevrio.rxlightning.com" target="_blank">Health Care Providers Begin Here</a> </div> </div> </div> <div class="modal-footer"> <button type="button" class="btn btn-default" data-dismiss="modal" name="Close" title="Close">Close</button> </div> </div> </div> </div> </div>  </div> <div class="col-lg-12"> </div> </div> </div> </form> <footer class="footer"> <div class="container"> <div class="row"> <div class="col-lg-7 col-md-6 col-sm-6"> <p>*This site is intended only for residents of the United States and Canada. 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