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Temporary Updates to the Terms and Conditions for the Merck Co-pay Assistance Program

Effective 06/01/2020 – 09/30/2021:

Patient will not have a minimum co-pay per administration of Program Product for any date of administration of Program Product between 06/01/2020 and 09/30/2021. The benefit available under the Co-pay Assistance Program is limited to the amount the patient's private health insurance company indicates on the Explanation of Benefits (EOB) that the patient is obligated to pay for Program Product, up to an annual maximum. The maximum Co-pay Assistance Program benefit per patient, per calendar year (January 1 through December 31), is $25,000.
- NOTE: Per the existing Terms and Conditions, for any date of administration of Program Product before 06/01/2020 or after 09/30/2021, patient must pay the first $25 of co-pay per administration of Program Product. The benefit available under the Co-pay Assistance Program is limited to the amount the patient's private health insurance company indicates on the EOB that the patient is obligated to pay for Program Product, less $25, up to an annual maximum. The maximum Co-pay Assistance Program benefit per patient, per calendar year (January 1 through December 31), is $25,000.
For any patient whose enrollment date begins on 06/01/2020 through 09/30/2021, the Program may apply to patient out-of-pocket costs incurred for Program Product within 150 days prior to the date patient is enrolled in the Co-pay Assistance Program, subject to annual Program maximum and the applicable Terms and Conditions based on Program Product administration date. Patient or provider may contact The Merck Access Program for more information.
- NOTE: Per the existing Terms and Conditions for patients who enrolled in the Program before 06/01/2020 and after 09/30/2021, the Program may apply to patient out-of-pocket costs incurred for Program Product within 90 days prior to the date patient is enrolled in the Co-pay Assistance Program, subject to annual Program maximum and the applicable Terms and Conditions based on Program Product administration date. Patient or provider may contact The Merck Access Program for more information.
For any Explanation of Benefits (EOB) from a patient's private health insurance that is dated between 06/01/2020 and 09/30/2021, the EOB must be submitted within 240 days of the date of the EOB for patient to receive co-pay assistance benefit; provided, however, that no EOB may be submitted more than 240 days after the expiration date of the Co-pay Assistance Program. The EOB must reflect the patient's out-of-pocket cost for Program Product and submission of the claim by the patient's provider for the cost of Program Product.
- NOTE: Per the existing Terms and Conditions, any EOB dated before 06/01/2020 or after 09/30/2021 from patient's private health insurance must be submitted within 180 days of the date of the EOB for patient to receive co-pay assistance benefit; provided, however, that no EOB may be submitted more than 180 days after the expiration date of the Co-pay Assistance Program. The EOB must reflect the patient's out-of-pocket cost for the Program Product and submission of the claim by the patient's provider for the cost of the Program Product.

All other Terms and Conditions for the Merck Co-pay Assistance Program remain in effect and must be satisfied to receive the benefit.

The Merck Co-pay Assistance Program (Medical Benefit)

TERMS AND CONDITIONS

To receive benefits under the Co-pay Assistance Program, the patient must enroll in the Co-pay Assistance Program and be accepted as eligible. Patient may contact The Merck Access Program for current Program Product(s) subject to these Terms and Conditions.
Patient must be prescribed the Program Product for an FDA-approved indication.
Patient must have private health insurance that provides coverage for the cost of the Program Product under a medical benefit plan.
The Co-pay Assistance Program is not valid for patients covered under Medicaid (including Medicaid patients enrolled in a qualified health plan purchased through a health insurance exchange [marketplace] established by a state government or the federal government), Medicare, a Medicare Part D or Medicare Advantage plan (regardless of whether a specific prescription is covered), TRICARE, CHAMPUS, Puerto Rico Government Health Insurance Plan (“Healthcare Reform”), or any other state or federal medical or pharmaceutical benefit program or pharmaceutical assistance program (collectively, “Government Programs”). The Co-pay Assistance Program is not valid for uninsured patients.
Subject to changes in state law, the Co-pay Assistance Program may become invalid for residents of Massachusetts prior to its expiration date.
Patient must have an out-of-pocket cost for the Program Product and be administered the Program Product prior to the expiration date of the Co-pay Assistance Program. The benefit available under the Co-pay Assistance Program is valid for the patient’s out-of-pocket cost for the Program Product only. It is not valid for any other out-of-pocket costs (for example, office visit charges or medication administration charges) even if such costs are associated with the administration of the Program Product. Claim for Program Product must be submitted by provider to patient’s private health insurance separately from other services and products.
Patient must pay the first $25 of co-pay per administration of Program Product. The benefit available under the Co-pay Assistance Program is limited to the amount the patient’s private health insurance company indicates on the Explanation of Benefits (EOB) that the patient is obligated to pay for the Program Product, less $25, up to an annual maximum. The maximum Co-pay Assistance Program benefit per patient, per calendar year (January 1 through December 31), is $25,000.
An EOB from patient’s private health insurance must be submitted within 180 days of the date of the EOB for patient to receive co-pay assistance benefit; provided, however, that no EOB may be submitted more than 180 days after the expiration date of Co-pay Assistance Program. The EOB must reflect the patient’s out-of-pocket cost for the Program Product and submission of the claim by the patient’s provider for the cost of the Program Product.
Patient and provider agree not to seek reimbursement for all or any part of the benefit received by the patient through the Co-pay Assistance Program. Patient and provider are responsible for reporting receipt of Co-pay Assistance Program benefits to any insurer, health plan, or other third party who pays for or reimburses any part of the medication cost paid for by the Co-pay Assistance Program, as may be required.
Patient must be a resident of the United States or the Commonwealth of Puerto Rico. Product must originate and be administered to patient in the United States or the Commonwealth of Puerto Rico.
The Program may apply to patient out-of-pocket costs incurred for Program Product within 90 days prior to the date patient is enrolled in the Co-pay Assistance Program, subject to annual Program maximum and the applicable Terms and Conditions based on Program Product administration date. Patient or provider may contact The Merck Access Program for more information.
All information applicable to the Co-pay Assistance Program requested on this form must be provided, and all certifications must be signed. Forms that are modified or do not contain all the necessary information will not be eligible for benefits under the Co-pay Assistance Program.
No other purchase is necessary.
The Co-pay Assistance Program is not insurance.
The Co-pay Assistance Program form may not be sold, purchased, traded, or counterfeited. Void if reproduced.
The Co-pay Assistance Program is void where prohibited by law, taxed, or restricted. The Co-pay Assistance Program is not transferable. No substitutions are permitted.
The Co-pay Assistance Program benefit cannot be combined with any other Co-pay Assistance Program, free trial, discount, prescription savings card, or other offer.
If acquiring Program Product from a Specialty Pharmacy (to be later administered in a physician office or outpatient institution), additional documentation may be required.
Merck reserves the right to rescind, revoke, or amend the Co-pay Assistance Program at any time without notice.
Data related to patient’s receipt of Co-pay Assistance Program benefits may be collected, analyzed, and shared with Merck, for market research and other purposes related to assessing Co-pay Assistance Programs. Data shared with Merck will be aggregated and de-identified, meaning it will be combined with data related to other Co-pay Assistance Program redemptions and will not identify patient.
These Terms and Conditions are valid for Program Product administered between January 1, 2021, and December 31, 2021.
Expiration Date: 12/31/2021.

US-KEY-03570 04/21

ENROLL NOW

Use the 2022 enrollment forms to enroll for the 2022 calendar year

Please click on the links below to access The Merck Access Program forms that are applicable to you. If you are requesting a referral to the Merck Patient Assistance Program, be sure to include all information, including a prescription from your health care provider for KEYTRUDA. Please be sure all signatures are included prior to submitting forms to The Merck Access Program.

Download and Print the Enrollment Form for Patients

Download & Print

These forms can be downloaded and printed, and require an original signature. Work with your health care provider to complete the enrollment form.

Electronically Sign and Submit the 2020 Enrollment Form for Patients

sign & submit electronically

This patient form can be signed and submitted electronically. Please note that your health care provider must also submit the Electronic Health Care Provider Enrollment Form.

Enrollment Assistance

Access the Sample Enrollment Form for Patients

Download and use this form as a guide
for completing the enrollment form.