LAGEVRIO™ 

(molnupiravir)  200 mg capsules [available for urgent request]

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.

LAGEVRIO 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 EUA and authorized labeling 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.

 

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 $60,240 or less for individuals, $81,760 or less for couples, or $124,800 or less for a family of 4.


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. 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

This product is ONLY available through an URGENT NEED request. Please call 800-727-5400 and tell the program representative that you are making an Urgent Need request for LAGEVRIO. Follow the program representative’s instructions. Do not mail in your enrollment form.

If you believe that you meet the eligibility criteria for the Merck Patient Assistance Program, call toll-free 800-727-5400 and tell the program representative that you are making an Urgent Need request for LAGEVRIO. Then follow the program representative's instructions to submit your request. Please ensure the following:

  1. Complete ALL information on the enrollment form, and sign in all designated areas.

  2. The physician/prescriber must write the prescription in Section 4 of the enrollment form.

    • 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.

Please Note:

This product is available only by Urgent Need Request. You must call 800-727-5400 and a program representative will help you. Do not mail in your enrollment form.

  • 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 enrollment form.
  • 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

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.

 
 
 
   
   


Download Enrollment Form (Application)

This product is ONLY available through an URGENT NEED request. Please call 800-727-5400 and tell the program representative that you are making an Urgent Need request for LAGEVRIO. Follow the program representative's instructions to make your request. Do not mail in your enrollment form.

Please download and complete the Enrollment Form (Application) from the link below:

English

Enrollment Form (Application)

Spanish

Enrollment Form (Application)

Please Note:

This product is available only by Urgent Need Request. You must call 800-727-5400 and a program representative will help you. Do not mail in your enrollment form.

  • 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 enrollment form.
  • 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.