Asmanex Hfa Patient Assistance Programs

Asmanex Hfa: Apply for prescription assistance below

If you are eligible, the programs below can help you afford Asmanex HFA. Review the information to see if you qualify. The applications are available in Adobe PDF format and should be mailed directly to the provider of the patient assistance program.

If you have any questions, please call the telephone number for the program (not PharmacyChecker.com) or go to the program website.

Looking for a different medication?

Merck Connect

(Program 1 of 9 — Scroll down to see them all )

Provided by: Merck & Co., Inc.
None
TEL: 800-489-5119
Languages Spoken:
English
Program Website
Program Applications and Forms
Medications
  • Asmanex HFA (mometasone furoate)
Eligibility Requirements
  • Insurance Status Determined case by case
  • Those with Part D Elibible? Determined case by case
  • Income Not disclosed
  • Diagnosis/Medical Criteria Medically Necessary as determined by a Doctor
  • U.S. Residency Required? Must be treated by US licensed healthcare provider
Application
  • Obtaining Enroll online
  • Receiving Not specified
  • Returning The completed application's destination is not specified
  • Doctor's Action Enroll in the program
  • Applicant's Action Inform Doctor that he/she is in need
  • Decision Communicated Not specified
  • Decision Timeframe Not specified
Medication
  • Amount/Supply Up to 30 day supply
  • Sent To Not specified
  • Delivery Time Not specified
  • Refill Proces Not specified
  • Limit Not specified
  • Re-application Not specified
Additional Information
Resources for HEALTHCARE PROFESSIONALS ONLY. The Physician must register to access tools and materials for patient support, product sample requests, up-to-date professional resources, and other Merck professional sites.
Updated November 9, 2018

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Merck Connect

(Program 2 of 9 — Scroll down to see them all )

Provided by: Merck & Co., Inc.
None
TEL: 800-489-5119
Languages Spoken:
English
Program Website
Program Applications and Forms
Medications
  • Asmanex HFA (mometasone furoate)
Eligibility Requirements
  • Insurance Status Determined case by case
  • Those with Part D Elibible? Determined case by case
  • Income Not disclosed
  • Diagnosis/Medical Criteria Medically Necessary as determined by a Doctor
  • U.S. Residency Required? Must be treated by US licensed healthcare provider
Application
  • Obtaining Enroll online
  • Receiving Not specified
  • Returning The completed application's destination is not specified
  • Doctor's Action Enroll in the program
  • Applicant's Action Inform Doctor that he/she is in need
  • Decision Communicated Not specified
  • Decision Timeframe Not specified
Medication
  • Amount/Supply Up to 30 day supply
  • Sent To Not specified
  • Delivery Time Not specified
  • Refill Proces Not specified
  • Limit Not specified
  • Re-application Not specified
Additional Information
Resources for HEALTHCARE PROFESSIONALS ONLY. The Physician must register to access tools and materials for patient support, product sample requests, up-to-date professional resources, and other Merck professional sites.
Updated November 9, 2018

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Merck Connect

(Program 3 of 9 — Scroll down to see them all )

Provided by: Merck & Co., Inc.
None
TEL: 800-489-5119
Languages Spoken:
English
Program Website
Program Applications and Forms
Medications
  • Asmanex HFA (mometasone furoate)
Eligibility Requirements
  • Insurance Status Determined case by case
  • Those with Part D Elibible? Determined case by case
  • Income Not disclosed
  • Diagnosis/Medical Criteria Medically Necessary as determined by a Doctor
  • U.S. Residency Required? Must be treated by US licensed healthcare provider
Application
  • Obtaining Enroll online
  • Receiving Not specified
  • Returning The completed application's destination is not specified
  • Doctor's Action Enroll in the program
  • Applicant's Action Inform Doctor that he/she is in need
  • Decision Communicated Not specified
  • Decision Timeframe Not specified
Medication
  • Amount/Supply Up to 30 day supply
  • Sent To Not specified
  • Delivery Time Not specified
  • Refill Proces Not specified
  • Limit Not specified
  • Re-application Not specified
Additional Information
Resources for HEALTHCARE PROFESSIONALS ONLY. The Physician must register to access tools and materials for patient support, product sample requests, up-to-date professional resources, and other Merck professional sites.
Updated November 9, 2018

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Merck Connect

(Program 4 of 9 — Scroll down to see them all )

Provided by: Merck & Co., Inc.
None
TEL: 800-489-5119
Languages Spoken:
English
Program Website
Program Applications and Forms
Medications
  • Asmanex HFA (mometasone furoate)
Eligibility Requirements
  • Insurance Status Determined case by case
  • Those with Part D Elibible? Determined case by case
  • Income Not disclosed
  • Diagnosis/Medical Criteria Medically Necessary as determined by a Doctor
  • U.S. Residency Required? Must be treated by US licensed healthcare provider
Application
  • Obtaining Enroll online
  • Receiving Not specified
  • Returning The completed application's destination is not specified
  • Doctor's Action Enroll in the program
  • Applicant's Action Inform Doctor that he/she is in need
  • Decision Communicated Not specified
  • Decision Timeframe Not specified
Medication
  • Amount/Supply Up to 30 day supply
  • Sent To Not specified
  • Delivery Time Not specified
  • Refill Proces Not specified
  • Limit Not specified
  • Re-application Not specified
Additional Information
Resources for HEALTHCARE PROFESSIONALS ONLY. The Physician must register to access tools and materials for patient support, product sample requests, up-to-date professional resources, and other Merck professional sites.
Updated November 9, 2018

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Merck Patient Assistance Program

(Program 5 of 9 — Scroll down to see them all )

Provided by: Merck Patient Assistance, Inc.
PO Box 690 Horsham, PA 19044-9979
TEL: 800-727-5400
Languages Spoken:
English, Spanish
Program Website
Medications
  • Nasonex spray; nasal (mometasone furoate monohydrate spray; nasal)
Eligibility Requirements
  • Insurance Status Determined case by case
  • Those with Part D Elibible? Contact program for details.
  • Income At or below 400% of FPL
  • Diagnosis/Medical Criteria Not specified
  • U.S. Residency Required? Must be residing in the US or a US territory, and under the care of a US physician
Application
  • Obtaining Call or download
  • Receiving Sent to doctor or patient
  • Returning Mail original application. Do not fax
  • Doctor's Action Complete section and sign
  • Applicant's Action Complete section and sign
  • Decision Communicated Call for decision
  • Decision Timeframe Up to 10 business days
Medication
  • Amount/Supply 90 day supply with up to 3 refills, for a total of up to 1 year of medications
  • Sent To Doctor's office or patient's home
  • Delivery Time Not specified
  • Refill Proces Patient requests refills via a toll-free number
  • Limit Not specified
  • Re-application New application yearly
Additional Information
At Merck we realize that sometimes exceptions need to be made based on the patient's individual circumstances. Individuals who do not meet the insurance criteria may still qualify for the Merck Patient Assistance Program if they attest that they have special circumstances of financial hardship, and their income meets the program criteria. *The Enrollment Form must be mailed. Please do not fax.
Updated November 8, 2018

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Merck Patient Assistance Program

(Program 6 of 9 — Scroll down to see them all )

Provided by: Merck Patient Assistance, Inc.
PO Box 690 Horsham, PA 19044-9979
TEL: 800-727-5400
Languages Spoken:
English, Spanish
Program Website
Medications
  • Nasonex spray; nasal (mometasone furoate monohydrate spray; nasal)
Eligibility Requirements
  • Insurance Status Determined case by case
  • Those with Part D Elibible? Contact program for details.
  • Income At or below 400% of FPL
  • Diagnosis/Medical Criteria Not specified
  • U.S. Residency Required? Must be residing in the US or a US territory, and under the care of a US physician
Application
  • Obtaining Call or download
  • Receiving Sent to doctor or patient
  • Returning Mail original application. Do not fax
  • Doctor's Action Complete section and sign
  • Applicant's Action Complete section and sign
  • Decision Communicated Call for decision
  • Decision Timeframe Up to 10 business days
Medication
  • Amount/Supply 90 day supply with up to 3 refills, for a total of up to 1 year of medications
  • Sent To Doctor's office or patient's home
  • Delivery Time Not specified
  • Refill Proces Patient requests refills via a toll-free number
  • Limit Not specified
  • Re-application New application yearly
Additional Information
At Merck we realize that sometimes exceptions need to be made based on the patient's individual circumstances. Individuals who do not meet the insurance criteria may still qualify for the Merck Patient Assistance Program if they attest that they have special circumstances of financial hardship, and their income meets the program criteria. *The Enrollment Form must be mailed. Please do not fax.
Updated November 8, 2018

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Merck Patient Assistance Program

(Program 7 of 9 — Scroll down to see them all )

Provided by: Merck Patient Assistance, Inc.
PO Box 690 Horsham, PA 19044-9979
TEL: 800-727-5400
Languages Spoken:
English, Spanish
Program Website
Medications
  • Nasonex spray; nasal (mometasone furoate monohydrate spray; nasal)
Eligibility Requirements
  • Insurance Status Determined case by case
  • Those with Part D Elibible? Contact program for details.
  • Income At or below 400% of FPL
  • Diagnosis/Medical Criteria Not specified
  • U.S. Residency Required? Must be residing in the US or a US territory, and under the care of a US physician
Application
  • Obtaining Call or download
  • Receiving Sent to doctor or patient
  • Returning Mail original application. Do not fax
  • Doctor's Action Complete section and sign
  • Applicant's Action Complete section and sign
  • Decision Communicated Call for decision
  • Decision Timeframe Up to 10 business days
Medication
  • Amount/Supply 90 day supply with up to 3 refills, for a total of up to 1 year of medications
  • Sent To Doctor's office or patient's home
  • Delivery Time Not specified
  • Refill Proces Patient requests refills via a toll-free number
  • Limit Not specified
  • Re-application New application yearly
Additional Information
At Merck we realize that sometimes exceptions need to be made based on the patient's individual circumstances. Individuals who do not meet the insurance criteria may still qualify for the Merck Patient Assistance Program if they attest that they have special circumstances of financial hardship, and their income meets the program criteria. *The Enrollment Form must be mailed. Please do not fax.
Updated November 8, 2018

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Rx Outreach Medications

(Program 8 of 9 — Scroll down to see them all )

Provided by: Rx Outreach
PO Box 66536 St. Louis, MO 63166-6536
TEL: 888-796-1234
FAX: 800-875-6591
Languages Spoken:
English, Spanish
Program Website
Medications
  • Elocon (mometasone furoate)
Eligibility Requirements
  • Insurance Status May have insurance
  • Those with Part D Elibible? Yes
  • Income At or below 300% of FPL
  • Diagnosis/Medical Criteria Not required
  • U.S. Residency Required? The patient must also be residing in the US.
Application
  • Obtaining Call, download or apply online
  • Receiving Faxed, mailed or downloaded from website
  • Returning Fax or E-Prescribe online
  • Doctor's Action Give prescription to patient
  • Applicant's Action Complete section and sign
  • Decision Communicated Medications sent if accepted. If denied patient and doctor notified
  • Decision Timeframe Usually same day
Medication
  • Amount/Supply Varies
  • Sent To Doctor's office or patient's home
  • Delivery Time Not specified
  • Refill Proces Company contacts patient to arrange
  • Limit Only limited by manufacturer's guidelines
  • Re-application New application yearly
Additional Information
Some medications are available for a fee of $20 for up to a 180 day supply. Check the Rx Outreach website for the exact price and most current medication list. Contact Program for Spanish Application(s)/Form(s).
Updated September 10, 2018

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Patient Access Network Foundation (PAN)

(Program 9 of 9 — Scroll down to see them all )

Provided by: Patient Access Network Foundation
None
TEL: 866-316-7263
FAX: 866-316-7261
Languages Spoken:
English, Spanish, Others By Translation Service
Program Website
Medications
  • Dulera (formoterol fumarate/mometasone furoate)
Eligibility Requirements
  • Insurance Status *See Additional Information section below
  • Those with Part D Elibible? Determined case by case
  • Income Between 400-500% of FPL
  • Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
  • U.S. Residency Required? Must reside and receive treatment in US
Application
  • Obtaining Call or complete online
  • Receiving Complete online or by phone
  • Returning Complete online or by phone
  • Doctor's Action Will be discussed with patient and Doctor after request is received
  • Applicant's Action Call for information or inform doctor that he/she is in need
  • Decision Communicated Patient and Doctor notified in writing
  • Decision Timeframe Within 48 hours
Medication
  • Amount/Supply Not applicable
  • Sent To Patient sent card to be used at pharmacy
  • Delivery Time Once approved; shipped same day
  • Refill Proces Patient presents voucher/card to pharmacy for each refill
  • Limit None
  • Re-application New application every 12 months
Additional Information
*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance. Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly. Note: All new enrollment is now done electronically or over the phone. Contact program for details.
Updated July 10, 2018

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