RESOURCES FOR PREVYMIS

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Electronic Enrollment

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 Healthcare Provider Enrollment Form This Healthcare Provider 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.

Enrollment

The Merck Access Program Enrollment Form This form can be downloaded and printed, and requires an original signature.
The Merck Access Program Spanish Enrollment Form
Potential Independent Foundation Support
Patient Representative's Form

Coverage and Reimbursement Support

Reimbursement Process Flashcard
Prior Authorization Checklist
Sample Prior Authorization Letter
Appeal Checklist
Sample Appeal Letter

Patient Support Materials

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Product Information

Physician Prescribing Information
Patient 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.