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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> EMEND<sup>®</sup></strong> </h2> <p class="genericName"> (aprepitant)  80 mg, 125 mg capsules [available for 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. </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 /><div class="row"> <div class="col-lg-2"> <div class="media"> <a href="https://youtu.be/iBw05i0itFE" target="_blank" title="Video on Enrollment Form"> <img src="/images/play_icon_sm.jpg" style="padding-top:5px;" /> </a> </div> </div> <div class="col-lg-10"> <p><a href="https://youtu.be/iBw05i0itFE" target="_blank">See a video on how to fill out the enrollment form </a></p> </div> </div> <div class="row"> <div class="col-lg-2"> <div class="media"> <a href="/MPAP/Merck PAP Medicines Checklist.pdf" target="_blank" title="Checklist for Enrollment Form"> <img src="/images/check.jpg" style="padding-top:5px;" /> </a> </div> </div> <div class="col-lg-10"> <p><a href="/MPAP/Merck PAP Medicines Checklist.pdf" target="_blank">Download an enrollment form checklist</a></p> </div> </div> <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> <p>If you need an <b>expedited request</b> for this product, 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 </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>If you believe that you meet the eligibility criteria for the Merck Patient Assistance Program and you have received a prescription for a Merck product, call toll-free 800-727-5400 8 AM to 8 PM ET to obtain a brochure outlining the program and an enrollment application, or proceed to Step 4 to download an enrollment form. After downloading the application or receiving your packet in the mail, follow these simple steps to submit your enrollment form for your free Merck medicines:</p> <ol style="list-style-type: none;"> <li class="one"> <p><b>Complete ALL information on the enrollment form.</b></p> <ul> <li>You may fill in the fields online and print it. <p class="bold">OR</p> </li> <li>You may print out the form and fill it out by hand using a black ballpoint pen.</li> </ul> </li> <li class="two"> <p><b>Take the completed enrollment form to your physician/prescriber. Both the physician/prescriber and the patient MUST sign the enrollment form.</b></p><br /> </li> <li class="three"> <p><b>Have your physician/prescriber write your prescription(s) in Section 4 of the enrollment form.</b></p> <ul> <li>A single enrollment form may include prescriptions for up to 3 Merck medicines. </li> <li>Each prescription may not exceed a 90-day supply at a time, with a maximum of 3 refills. </li> <li>Each enrollment form 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> <li class="four"> <p><b>Mail completed enrollment forms to:</b></p> <p>Merck Patient Assistance Program<br /> PO Box 690<br /> Horsham, PA 19044-9979</p> </li> </ol> <div class="enrollment"> <h4>Please Note:</h4> <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 application. </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> </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-xs-12"> <h2>Enrollment Options</h2> <p>You may have your enrollment form faxed to <strong class='green-text-color'>915-921-8539</strong>, enroll online, print and mail the enrollment form, or request an enrollment form by calling 800-727-5400.</p><br /> </div> <div class="col-lg-4" style="~~FaxEntrollment~~"> <p class="enrollmentOptionNumber" style="~~OnlyOneOption~~">Option 1:</p> <h3>Print and Fax</h3> <div class="fake-ol"> <div class="li"> <div class="olNumber"><div>1</div></div> <div class="content"> <h5>Download and complete the Enrollment Application Form:</h5> <a href="/MPAP/MPAP_Enrollment_Form_US-NON-11869_English.pdf" class="btn btn-primary downloadButton" download> <span><strong>English</strong> Enrollment Application Form</span> <img class="downloadIcon" src="/images/download-icon.png" /> </a> <a href="/MPAP/MPAP_Enrollment_Form_US-NON-13238_Spanish.pdf" class="btn btn-primary downloadButton" download> <span><strong>Spanish</strong> Enrollment Application Form</span> <img class="downloadIcon" src="/images/download-icon.png" /> </a> </div> </div> <div class="li"> <div class="olNumber"><div>2</div></div> <div class="content"> <h5>Fax Enrollment Application Form to:</h5> <p>915-921-8539</p> </div> </div> </div> </div> <div class="col-lg-4" style="~~OnlineEnrollment~~"> <p class="enrollmentOptionNumber" style="~~OnlyOneOption~~">Option 2:</p> <h3>Online Enrollment</h3> <p>Now, you can make enrolling easier with the new online application process.</p> <a href="#" target="_blank" class="btn btn-primary green-bg-color buttonOnlineEnrollment" data-toggle="modal" data-target="#onlineEnrollment"> Begin Online Enrollment Form </a> </div> <div class="col-lg-4"> <p class="enrollmentOptionNumber" style="~~OnlyOneOption~~">Option 3:</p> <h3>Print and Mail</h3> <div class="fake-ol"> <div class="li"> <div class="olNumber"><div>1</div></div> <div class="content"> <h5>Download and complete the Enrollment Application Form:</h5> <a href="/MPAP/MPAP_Enrollment_Form_US-NON-11869_English.pdf" class="btn btn-primary downloadButton" download> <span><strong>English</strong> Enrollment Application Form</span> <img class="downloadIcon" src="/images/download-icon.png" /> </a> <a href="/MPAP/MPAP_Enrollment_Form_US-NON-13238_Spanish.pdf" class="btn btn-primary downloadButton" download> <span><strong>Spanish</strong> Enrollment Application Form</span> <img class="downloadIcon" src="/images/download-icon.png" /> </a> </div> </div> <div class="li"> <div class="olNumber"><div>2</div></div> <div class="content"> <h5>Mail Enrollment Application Form to:</h5> <p>Merck Patient Assistance Program<br />PO Box 690<br />Horsham, PA 19044-9979</p> </div> </div> </div> </div> <div class="col-xs-12"> <div class="needAssistanceBox"> <h5>Important Information:</h5> <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>Please discuss the risks and benefits of all medicines with your health care provider and take only as prescribed by your health care provider.</li> </ul><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="btn btn-primary green-bg-color buttonPanel" href="https://merckhelps.knipperx.com" target="_blank">Patients Begin Here</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://Emend.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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