KEYTRUDA® (pembrolizumab) | The Merck Co-Pay Assistance Program

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Notice to Qualified Health Plans:

After careful consideration and deliberation, including analysis of the October 30, 2013, and February 6, 2014, letters from former Secretary Sebelius to Representative McDermott (D-WA) and Senator Grassley (R-IA), respectively, Merck has decided to make a co-payment assistance program for this Product available to enrollees of a health insurance exchange established by a state government or the federal government who are not Medicaid eligible. The terms and conditions of our patient co-payment assistance program are set forth below.

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 be 18 years of age or older and 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.
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 physician 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 for patients with an Annual Gross Household Income of less than or equal to 700% of the current Federal Poverty Level, and $10,000 for patients with an Annual Gross Household Income of more than 700% of the current Federal Poverty Level.
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 physician for the cost of the Program Product.
Patient and physician 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 physician 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 physician 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. Benefits are not available through this Co-pay Assistance Program for product purchased by patient at a pharmacy, even if later administered in a physician office or outpatient institution.
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, 2017, and December 31, 2017.
Expiration Date: 12/31/2017.
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 or physician 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 be 18 years of age or older and 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.
Absent a change in Massachusetts law, effective July 1, 2015, the Co-pay Assistance Program will no longer be valid for residents of Massachusetts.
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 physician to patient's private health insurance separately from other services and products.
Patient must pay the first $50.00 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 $50.00, 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 patients with an Annual Gross Household Income of less than or equal to 700% of the current Federal Poverty Level, and $10,000 for patients with an Annual Gross Household Income of more than 700% of the current Federal Poverty Level.
An EOB from patient's private health insurance must be submitted within 90 days of the date of the EOB for patient to receive Co-pay Assistance Program benefit; provided, however, that no EOB may be submitted more than 90 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 physician for the cost of the Program Product.
Patient and physician 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 physician 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.
Patients who are determined to be eligible for benefits under the Co-pay Assistance Program in one calendar year (January 1 through December 31) must reenroll and be reapproved the following calendar year. 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 these Terms and Conditions. Patient or physician 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. Benefits are not available through this Co-pay Assistance Program for product purchased by patient at a pharmacy, even if later administered in a physician's office or outpatient institution.
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 to 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.
Expiration Date: 12/31/2015.

ONCO-1148163-0003 11/16

THE MERCK CO-PAY ASSISTANCE PROGRAM

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