RESOURCES FOR PREVYMIS

RESOURCE

CLICK HERE

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 Health Care Provider Enrollment Form This Health Care 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

Available Independent Foundation Support

Representative’s Form

Coverage and reimbursement information

Prior Authorization Checklist

Sample Prior Authorization Letter

Appeal Checklist

Sample Appeal Letter

Patient support materials

prevymis.com

Product information

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.