ELOCON® 

(mometasone furoate) 

This product qualifies for the Merck Patient Assistance Program. 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:

  1. You are a US resident and have a prescription for a Merck product from a health care provider licensed in the United States.*

    AND

  2. 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.

    AND

  3. You cannot afford to pay for your medicine. You may qualify for the program if you have a household income of $48,240 or less for individuals, $64,960 or less for couples, or $98,400 or less for a family of 4.


At Merck we realize that sometimes exceptions need to be made based on the patient's individual circumstances. If you do not meet the prescription drug 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.

* You do not have to be a US citizen. Legal residents of the United States, including US Territories, are also eligible.

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 1-800-727-5400 8 AM to 8 PM EST to obtain a brochure outlining the program and an enrollment application, or by clicking on the link on the right. 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:

  1. 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.

  2. Take the completed application to your physician/prescriber. Both the physician/prescriber and the patient MUST sign the application.


  3. Have your physician/prescriber write your prescription(s) in Section 2 of the application.

    • A single application 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 application is valid for up to 12 months; after 12 months a new application will be required. Under certain circumstances, enrollment may be limited to a calendar year.

  4. Mail completed applications to:

    Merck Patient Assistance Program
    PO Box 690
    Horsham, PA 19044-9979

Please Note:

  • Incomplete or incorrectly completed applications will be returned.
  • Section 2 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 3 of the application.
  • For additional applications or assistance, please call 1-800-727-5400.

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

Please answer these short questions to see if you may qualify. You must answer ALL questions on this page to be considered.
This information is not collected or retained.