Merck Patient Assistance Program for PREVYMIS™ (letermovir)

Welcome to

THE MERCK ACCESS PROGRAM

ARE YOU A US HEALTHCARE PROFESSIONAL?

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This link will take you to a site outside of Merck & Co., Inc. that is managed by a third-party administrator of The Merck Access Program. Merck does not endorse and is not responsible for the accuracy, content, practices, or standards of any non-Merck site.

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Annual Re-enrollment

The Merck Access Program (MAP) Enrollment Forms Are Now Available

Please utilize the updated MAP Enrollment Form to re-enroll your patients:

Complete the new Healthcare Provider Enrollment Form for each patient who requires re-enrollment. You may submit the application online, or print and fax the completed forms
Ensure the patient also completes the Patient Enrollment Form
Ensure that all enrollment forms are submitted as soon as you receive a notification from MAP

A member from MAP will reach out to you and your patient after the enrollment form is submitted.

US-NON-13838 09/23

Re-enroll for 2024

The Merck Access Program (MAP) Enrollment Forms Are Now Available

If you received a re-enrollment letter from The Merck Access Program and would like to re-enroll:

Complete the new enrollment form and submit it online, or print and fax the completed downloadable form
Contact your Healthcare Provider to confirm they have also completed the Healthcare Provider Enrollment Form
Ensure that all enrollment forms are submitted as soon as you receive a notification from MAP

A member from MAP will reach out to you and your healthcare provider after the enrollment form is submitted.

US-NON-13837 09/23

By clicking on this link, you will be leaving this site.

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REMEMBER TO:

	Download and print the enrollment form

	Complete and sign the patient sections of the enrollment form (pages 1-4)

	Make sure your healthcare provider reads and signs the healthcare provider section of the enrollment form (pages 5-6)

	Fax or ask your healthcare provider to help you fax your enrollment form to 866-866-4127

REMEMBER TO:

	Download and print the enrollment form

	Complete and sign the patient sections of the enrollment form (pages 1-4)

	Make sure your healthcare provider reads and signs the healthcare provider section of the enrollment form (pages 5-6)

	Fax or ask your healthcare provider to help you fax your enrollment form to 866-866-4127

REMEMBER TO:

	Use this option to complete the enrollment form electronically

	Make sure you talk to your healthcare provider if you have any questions or concerns

	Fill out your name and the date when asked on the form

	Complete and sign all relevant sections of the enrollment form

	Submit the form electronically

	Ask your healthcare provider to complete and submit the Healthcare Provider Enrollment Form

REMEMBER TO:

Sign & Submit Electronically

REMEMBER TO: Sign & Submit Electronically

	Use this option to complete the enrollment form electronically with the patient

	Fill out and sign the healthcare provider section of the enrollment form

	Inform the patient that they will receive an email from The Merck Access Program to complete the enrollment form

	Instruct the patient to complete and sign the patient sections of the enrollment form

	Submit the form electronically

REMEMBER TO:

Download & Print

REMEMBER TO: Download & Print

	Download and print the enrollment form

	Instruct the patient to complete and sign the patient sections of the enrollment form (pages 1-4)

	Fill out and sign the healthcare provider section of the enrollment form (pages 5-6)

	Include a copy of the front and back of the patient’s insurance card

	Fax the completed form to 866-866-4127

REMEMBER TO:

	Download and print the enrollment form

	Instruct the patient to complete and sign the patient sections of the enrollment form (pages 1-4)

	Fill out and sign the healthcare provider section of the enrollment form (pages 5-6)

	Include a front and back copy of the patient’s insurance card

	Fax the completed form to 866-866-4127

REMEMBER TO:

	Complete the patient and insurance information (page 1)

	Fill out and sign the healthcare provider section of the enrollment form (pages 2-3)

	Submit the form electronically

	Ensure the patient also completes the Electronic Patient Enrollment Form, found at merckaccessprogram-prevymis.com/hcc

This site is intended only for residents of the United States.