Questions? Contact The Merck Access Program at 877-709-4455 Mon–Fri, 8 AM to 8 PM ET, to speak to a representative.
Questions? Contact The Merck Access Program at 877-709-4455 Mon–Fri, 8 AM to 8 PM ET, to speak to a representative.
The Merck Co-pay Assistance Program for ZINPLAVA™ (bezlotoxumab) Injection 25 mg/mL ("Program Product")
US-MKB-00718 11/23
Learn More About Enrollment
THE MERCK
ACCESS PROGRAM
This form can be downloaded and printed, and requires an original signature. Work with your healthcare provider to complete the enrollment form.
This form can be downloaded and printed, and requires an original signature. Work with your healthcare provider to complete the enrollment form.
This patient form can be signed and submitted electronically. Please note that your healthcare provider must also submit the
Healthcare Provider Enrollment Form.
This patient form can be signed and submitted electronically. Please note that your healthcare provider must also submit the Healthcare Provider Enrollment Form.
Electronic Patient Enrollment FormEnrollment Support
Do you have a legal and/or personal representative who is helping
you with your application? If so, this person must fill out this form and fax it to 800-977-1957.
The Merck Co-pay Assistance Program for ZINPLAVA™ (bezlotoxumab) Injection 25 mg/mL ("Program Product")
US-MKB-00718 11/23