Prescriptions for WELIREG can be filled through EITHER the specialty pharmacy network or certain physician practices with dispensing capabilities and certain hospital pharmacies.
Merck is not affiliated with and does not endorse one specialty pharmacy over another.
The Merck Access Program May Be Able to Help Answer Questions About:
- Benefits investigations
- Prior authorizations and appeals
- Potential financial assistance options for eligible patients, including information about co-pay assistance for eligible, privately insured patients
- Referral to the Merck Patient Assistance Program for eligibility determination (provided through the Merck Patient Assistance Program, Inc.)
Please click on the links below to access The Merck Access Program forms that are applicable to you. If your patient is requesting a referral to the Merck Patient Assistance Program, be sure to include all information, including a prescription for WELIREG. Please be sure all signatures are included prior to submitting forms to The Merck Access Program.
| SIGN & SUBMIT ELECTRONICALLY | DOWNLOAD | |
|---|---|---|
Patient and Physician Enrollment Form |  |  |
Patient Enrollment Form | | |
Physician Enrollment Form | | |
Patient and Physician Enrollment Form | |
| SIGN & SUBMIT ELECTRONICALLY |  |
OR | |
| DOWNLOAD & PRINT |  |
Patient Enrollment Form | |
| SIGN & SUBMIT ELECTRONICALLY | |
OR | |
| DOWNLOAD & PRINT | |
Physician Enrollment Form | |
| SIGN & SUBMIT ELECTRONICALLY | |
OR | |
| DOWNLOAD & PRINT | |
