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To get started, select a category above or call 855-404-5278 to speak with a representative, Monday through Friday, 8AM to 8PM ET

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Coverage & Reimbursement

Co-pay Assistance Options for Eligible Patients

The Merck Patient Assistance Program

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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

Healthcare Professionals Patients and Caregivers

Physician Prescribing Information | Patient Information

Learn More About Enrollment

THE MERCK ACCESS PROGRAM

The Merck Access Program is designed to provide reimbursement and insurance coverage-related information for your patient throughout their treatment process.

	SIGN & SUBMIT ELECTRONICALLY	DOWNLOAD & PRINT
Enrollment Form Helpful Hints

Spanish Enrollment Form Helpful Hints

Electronic Healthcare Provider Enrollment Form The patient must also submit the Electronic Patient Enrollment Form. Helpful Hints

Enrollment Form

Helpful Hints

SIGN & SUBMIT ELECTRONICALLY

Download & Print

Spanish Enrollment Form

Helpful Hints

DOWNLOAD & PRINT

Electronic Healthcare Provider Enrollment Form

The patient must also submit the Electronic Patient Enrollment Form.

Helpful Hints

SIGN & SUBMIT ELECTRONICALLY

Enrollment Support

Patient Representative’s Form

Does your patient have a legal and/or personal representative who is assisting them? If so, it’s important that you have the representative fill out this form.

Submit Documents

Use this link to securely upload documents to submit to The Merck Access Program.

	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

	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

	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

	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

	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

	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