| Pharmaceutical Company | Merck Patient Assistance Program for Aggrestat |
| Program Address | P. O. Box 222137 Charlotte, NC 28222-2137 |
| Toll Free Phone Number | 877-810-0595 |
| Alternate Phone Number | None |
| Fax Number | None |
| Guidelines and Notes | This program is for those who are completely uninsured and meet their financial guidelines. It's a product replacement program. A hospital social worker will typically use the program after an uninsured patient is treated with the drug. |
| Initiating Enrollment | The hospital calls to get an application. The form may be copied. The caller must have the hospital's DEA number, a contact person's name, and the hospital's address. The application is faxed to the hospital. |
| Health Provider's Role | The doctor's name must be on the application. A hospital representative (usually a social worker) signs it. The pharmacy dispensing record and drug invoice must be sent in with the application. |
| Patient's Role | Must provide detailed and financial information and proof of household income. |
| How Dispensed | Sent to hospital pharmacy |
| Amount Dispensed | Replacement of amount used |
| Estimated Response Time | Not specificied |
| Refills | N.A. |
| Limit | N.A. |