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Temporary Updates to the Terms and Conditions for the Merck Co-pay Assistance Program - ZINPLAVA™ (bezlotoxumab) Injection 25 mg/mL
EFFECTIVE 06/01/2020 – 09/30/2021:
All other Terms and Conditions for The Merck Co-pay Assistance Program remain in effect and must be satisfied to receive the benefit. If you have any questions, please contact The Merck Access Program at 877-709-4455 from 8 AM to 8 PM ET, Monday through Friday.
Terms and Conditions for the Co-pay Assistance Program for ZINPLAVA™ (bezlotoxumab) Injection 25 mg/mL:
Please click on the links below to access The Merck Access Program forms that are applicable to you. If you are requesting a referral to the Merck Patient Access Program, be sure to include all information, including a prescription from your health care provider for ZINPLAVA. Please be sure all signatures are included prior to submitting forms to The Merck Access Program.
This form can be downloaded and printed, and requires an original signature. Work with your health care provider to complete the enrollment form.
This patient form can be signed and submitted electronically. Please note that your health care provider must also submit the Health Care Provider Enrollment Form.
Electronic Patient Enrollment Form