Professional Resources and Forms for PREVYMIS™ (letermovir)

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

Resources

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

RESOURCES FOR PREVYMIS

RESOURCE

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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

prevymis.com

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.

	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