To get started, select a category above or call 855-404-5278 to speak with a representative, Monday through Friday, 8AM to 8PM ET
To get started, select a category above or call 855-404-5278 to speak with a representative, Monday through Friday, 8 AM to 8 PM ET
CO-PAY COUPON For Prevymis
YOUR ELIGIBLE PRIVATELY INSURED PATIENTS MAY SAVE ON PREVYMIS
Eligible patients may visit prevymis.com to learn more.
Not all patients are eligible.
Certain restrictions apply.
Independent Foundation Support
Your patients may also be able to get help from an independent co-pay assistance foundation
Independent co-pay assistance foundations may be able to help patients who are encountering hardships affording their prescribed medications or who do not qualify for other forms of financial support.
Each foundation determines its own eligibility criteria and application process and is independent from Merck; there is no guarantee a patient will receive any type of assistance from these organizations.
REMEMBER TO: 
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Download and print the enrollment form |
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Complete and sign the patient sections of the enrollment form (pages 1-4) |
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Make sure your healthcare provider reads and signs the healthcare provider section of the enrollment form (pages 5-6) |
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Fax or ask your healthcare provider to help you fax your enrollment form to 866-866-4127 |
REMEMBER TO:
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Download and print the enrollment form |
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Complete and sign the patient sections of the enrollment form (pages 1-4) |
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Make sure your healthcare provider reads and signs the healthcare provider section of the enrollment form (pages 5-6) |
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Fax or ask your healthcare provider to help you fax your enrollment form to 866-866-4127 |
REMEMBER TO:
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Use this option to complete the enrollment form electronically |
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Make sure you talk to your healthcare provider if you have any questions or concerns |
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Fill out your name and the date when asked on the form |
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Complete and sign all relevant sections of the enrollment form |
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Submit the form electronically |
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Ask your healthcare provider to complete and submit the Healthcare Provider Enrollment Form |
REMEMBER TO:
Sign & Submit Electronically
REMEMBER TO: Sign & Submit Electronically
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Use this option to complete the enrollment form electronically with the patient |
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Fill out and sign the healthcare provider section of the enrollment form |
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Inform the patient that they will receive an email from The Merck Access Program to complete the enrollment form |
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Instruct the patient to complete and sign the patient sections of the enrollment form |
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Submit the form electronically |
REMEMBER TO:
Download & Print
REMEMBER TO: Download & Print
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Download and print the enrollment form |
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Instruct the patient to complete and sign the patient sections of the enrollment form (pages 1-4) |
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Fill out and sign the healthcare provider section of the enrollment form (pages 5-6) |
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Include a copy of the front and back of the patient’s insurance card |
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Fax the completed form to 866-866-4127 |
REMEMBER TO:
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Download and print the enrollment form |
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Instruct the patient to complete and sign the patient sections of the enrollment form (pages 1-4) |
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Fill out and sign the healthcare provider section of the enrollment form (pages 5-6) |
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Include a front and back copy of the patient’s insurance card |
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Fax the completed form to 866-866-4127 |
REMEMBER TO:
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Complete the patient and insurance information (page 1) |
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Fill out and sign the healthcare provider section of the enrollment form (pages 2-3) |
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Submit the form electronically |
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Ensure the patient also completes the Electronic Patient Enrollment Form, found at merckaccessprogram-prevymis.com/hcc |
