Merck Programs to Help Those in Need

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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_MAP.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> KEYTRUDA<sup>®</sup></strong> </h2> <p class="genericName"> (pembrolizumab)  Injection [liquid formulation] 100 mg </p> <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.</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">855-257-3932</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</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>You may qualify for patient assistance<sup>(1)</sup> if you meet all 3 of the following conditions:</p> <ol style="list-style-type: none; margin-left: 0px;"> <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>(2)</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>(3)</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 patient assistance program if you have a household income of $78,250 or less for individuals, $105,750 or less for couples, or $160,750 or less for a family of 4.<sup>(4)</sup></p></li></ol> <br /> <p></p>  <p><sup>(1)</sup> Offered through the Merck Patient Assistance Program, Inc.</p> <p><sup>(2)</sup> You do not have to be a US citizen. Legal residents of the United States, including US Territories, are also eligible.</p> <p><sup>(3)</sup> If you do not meet the insurance coverage criteria, your income meets the program criteria, and there are special circumstances of financial and medical hardship that apply to your situation, you can request that an exception be made for you. Patients may not have an insurance plan or employer that participates in or are involved in any way with an alternative funding program that requires or encourages you to apply to the Merck Patient Assistance Program as a condition, requirement, or prerequisite for coverage of specific Merck medications.</p> <p><sup>(4)</sup> For income limits in Alaska and Hawaii, please call 1-800-727-5400.</p> </div> <h3 class="howtogetstarted">How to Get Started</h3> <div class="tab-pane" id="started"> <p>To apply for the Merck Patient Assistance Program for KEYTRUDA<sup>®</sup>, you must complete an Enrollment Form for the Merck Access Program. The Merck Access Program provides support to help answer questions related to insurance coverage and reimbursement.</p> <p>You and your health care provider can call the Merck Access Program at 855-257-3932 to request an enrollment form. The Merck Access Program Representatives are available 8 AM to 8 PM ET, Monday through Friday, to answer questions about the program.</p> </div> <h3 class="checkyoureligibility">Check Your Eligibility</h3> <div class="tab-pane" id="eligibility"> <div class="form-horizontal"> <script type="text/javascript"> //<![CDATA[ Sys.WebForms.PageRequestManager._initialize('ctl00$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> <p>To access the KEYTRUDA® enrollment form, click <a href="JavaScript:extLinkMH('https://www.merckaccessprogram-keytruda.com/hcc/');">here</a>.</p> </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 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