The Merck Access Program Electronic Enrollment Form This form can be signed and submitted electronically. Use the form only if the patient is in the office and you are able to complete the form together.
The Merck Access Program Electronic Health Care Provider Enrollment Form This form can be signed and submitted electronically. Please note that the patient must also submit the Electronic Patient Enrollment Form, which can be found at www.merckaccessprogram-prevymis.com/hcc.
The Merck Access Program Enrollment Form
Available Independent Foundation Support
Coverage and reimbursement information
Prior Authorization Checklist
Sample Prior Authorization Letter
Patient support materials
Physician Prescribing Information
Patient Product Information
The information available here is compiled from sources believed to be accurate, but Merck makes no representation that it is accurate. This information is subject to change. Payer coding requirements may vary or change over time, so it is important to regularly check with each payer as to payer-specific requirements.
The information available here is not intended to be definitive or exhaustive, and is not intended to replace the guidance of a qualified professional advisor. Merck and its agents make no warranties or guarantees, express or implied, concerning the accuracy or appropriateness of this information for your particular use given the frequent changes in public and private payer billing. The use of this information does not guarantee payment or that any payment received will cover your costs.
For more information, contact The Merck Access Program at 855-404-5278 Mon–Fri, 8 AM to 8 PM (ET), to speak to a representative.