The Merck Access Program for KEYTRUDA® (pembrolizumab)

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THE MERCK ACCESS PROGRAM

The Merck Access Program is designed to provide reimbursement and insurance coverage–related information for you throughout your treatment process.

Enrollment Form

You and your healthcare provider must complete and submit the Enrollment Form.

Patient Enrollment Form

Your healthcare provider must also submit the Healthcare Provider Enrollment Form.

Program Opt-out Form

SIGN & SUBMIT
ELECTRONICALLY

O

R

DOWNLOAD
& PRINT

Enrollment Form

You and your healthcare provider must complete and submit the Enrollment Form.

DOWNLOAD & PRINT

Patient Enrollment Form

Your healthcare provider must also submit the Healthcare Provider Enrollment Form.

SIGN & SUBMIT ELECTRONICALLY

OR

DOWNLOAD
& PRINT

Program Opt-out Form

SIGN & SUBMIT ELECTRONICALLY

ENROLLMENT SUPPORT

Sample Enrollment Form

This sample form is a helpful resource that outlines important details and steps while you are filling out the enrollment form to ensure that all information and signatures are captured.

The Merck Co-pay Assistance Program

TERMS AND CONDITIONS

The Merck Co-pay Assistance Program for KEYTRUDA^® (pembrolizumab) Injection 100 mg ("Program Product")

To receive benefits under the Co-pay Assistance Program, the patient must enroll in the Co-pay Assistance Program and be accepted as eligible. A patient's eligibility for the Co-pay Assistance Program will commence upon the date of The Merck Access Program’s acceptance of patient’s enrollment and will continue for twelve months thereafter (“Eligibility Period”), so long as the patient satisfies all eligibility criteria of the Co-pay Assistance Program for each date of administration of the Program Product. A patient may contact The Merck Access Program to inquire about the current Program Product(s) that are 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 or a pharmacy 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.
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.
Subject to changes in state law, the Co-pay Assistance Program may become invalid for residents of Massachusetts prior to its expiration date.
All information applicable to the Co-pay Assistance Program requested on The Merck Access Program Enrollment 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.
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 indicated on the documentation provided by the patient's private health insurance company, which can include, but is not limited to, an Explanation of Benefits (EOB) or a Remittance Advice (RA), that the patient is obligated to pay for the Program Product, less $25, up to the Co-pay Assistance Program per patient maximum. The maximum Co-pay Assistance Program benefit per patient per Eligibility Period is $25,000.
Patient must have an out-of-pocket cost for the Program Product and be administered the Program Product during the patient's Eligibility Period or the 90-Day Lookback Period (defined below) AND during the Term (defined below) 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. The claim for Program Product must be submitted by the patient's healthcare provider or pharmacy (both referred to as "Provider") to patient's private health insurance separately from other services and products.
To receive the benefit available under the Co-pay Assistance Program, patient or Provider must submit documentation provided by the patient's private health insurance company that contains the following information: name of the patient's private health insurance company, patient's insurance plan details (patient ID, policy/group/payor ID, and, for pharmacy benefit claims only, BIN and PCN), patient's demographic information (full name, date of birth, and address), patient's out-of-pocket cost for Program Product, confirmation that the Program Product was administered to the patient, date of Program Product administration to the patient, and submission of the claim by the Provider for the cost of the Program Product. The documentation must also show that the Program Product was paid separately from other services and products.
The documentation provided by the patient's private health insurance company, which can include, but is not limited to, an EOB or RA, must be submitted to the Co-pay Assistance Program within 180 days of the date the claim was processed for patient to receive a co-pay assistance benefit; provided, however, that no claims may be submitted more than 180 days after the expiration date of Co-pay Assistance Program.
The Co-pay Assistance Program may apply to patient out-of-pocket costs incurred for a Program Product that was administered up to 90 days prior to the start date of the patient's Eligibility Period ("90-Day Lookback Period"), subject to the Co-pay Assistance Program per patient 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.
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.
No other purchase is necessary.
The Co-pay Assistance Program is not insurance.
The Merck Access Program Enrollment 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.
The term of the Co-pay Assistance Program is from August 1, 2023, through October 30, 2025 ("Term"). A patient may have only one Eligibility Period during the Term of the Co-pay Assistance Program. Enrollment into the Co-pay Assistance Program will automatically terminate patient's eligibility in any other Merck co-pay assistance program for Program Product.
Program Group Number: 2395, Expiration Date: 10/30/2025

US-KEY-06986 08/23