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Patient Information

Note: the coupon can only be used if you activate it prior to filling your prescription. It cannot be used with a previous prescription purchase.

Need help? Call 877-264-2454

STEPS

Eligible, privately insured patients may pay as little as $0 per prescription on each qualifying prescription. Maximum program savings is $9,450 per patient. Coupon may be redeemed once every 21 days before the expiration date printed on the coupon, on each qualifying prescription up to a 90-day supply. Not all patients are eligible. Terms and Conditions apply.

Please enter the following patient information exactly as it appears on the insurance card.

^* Required Fields

We're sorry, but you must be 18 years or older to get a coupon. If the information entered was incorrect, please correct below and resubmit. Otherwise, you may select Cancel below.

^* First Name

^* Last Name

^*Date of Birth

^* ZIP Code

By consenting and providing the requested information below, you agree that the administrator of Merck's coupon program, on behalf of Merck, will collect and use the information provided, as well as sensitive personal information about the product and prescription related to the coupon you are requesting, to determine eligibility for the coupon, and if eligible, provide it to you or your child or ward (collectively, "patient"), as applicable. For more information about Merck's privacy policies and/or your rights, please see Merck's U.S Privacy Notice and Consumer Health Data Privacy Policy. You can withdraw your consent to processing of your pesonal information, or the patient's personal information, as applicable, for these purposes at any time by clicking here.

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^* I consent to the collection and use of my and/or the patient's personal information as described above.