JANUMET® XR
(sitagliptin and metformin HCI extended-release) Tablets
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.
Who May Qualify
If you have been prescribed a Merck medicine, you may be eligible for the program if all 3 of the following conditions apply:
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You are a US resident and have a prescription for a Merck product from a health care provider licensed in the United States.(1)
AND
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You do not 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.(2)
AND
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You cannot afford to pay for your medicine. You may qualify for the program if you have a household income of $60,240 or less for individuals,
$81,760 or less for couples, or $124,800 or less for a family of 4.(3)
(1) You do not have to be a US citizen. Residents of the United States, including US Territories, are also eligible.
(2) 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.
(3) For income limits in Alaska and Hawaii, please call 1-800-727-5400.
How to Get Started
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:
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Complete ALL information on the enrollment form.
- You may fill in the fields online and print it.
OR
- You may print out the form and fill it out by hand using a black ballpoint pen.
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Take the completed enrollment form to your physician/prescriber. Both the physician/prescriber and the patient MUST sign the enrollment form.
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Have your physician/prescriber write your prescription(s) in Section 4 of the enrollment form.
- A single enrollment form may include prescriptions for up to 3 Merck medicines.
- Each prescription may not exceed a 90-day supply at a time, with a maximum of 3 refills.
- 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.
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Mail completed enrollment forms to:
Merck Patient Assistance Program
PO Box 690
Horsham, PA 19044-9979
Please Note:
- Incomplete or incorrectly completed enrollment forms will be returned.
- Section 4 is your prescription. Your physician/prescriber does not need to write your prescription on a separate prescription form.
- Your medication will be sent to your home address unless otherwise requested by the physician/prescriber in Section 1 of the application.
- For additional enrollment forms or assistance, please call 800-727-5400.
Other Important Information
Please discuss the risks and benefits of all medicines with your health care provider and take only as prescribed by your health care provider.
Check Your Eligibility
Download Enrollment Form (Application)
Please download and complete the Enrollment Form (Application) on this page or you may call 800-727-5400 if you need
assistance.
Mail completed enrollment forms (applications) to:
Merck Patient Assistance Program
PO Box 690
Horsham, PA 19044-9979
Online Option for Patients Coming Soon!
Please Note:
- Incomplete or incorrectly completed enrollment forms (applications) will be returned.
- Section 4 is your prescription. Your physician/prescriber does not need to write your prescription on a separate prescription form.
- Your medication will be sent to your home address unless otherwise requested by the physician/prescriber in Section 1 of the application.
- For additional enrollment forms or assistance, please call 800-727-5400.
Other Important Information
Please discuss the risks and benefits of all medicines with your health care provider and take only as prescribed by your health care provider.