The Merck Access Program for KEYTRUDA® (pembrolizumab)

Pacientes y cuidadores Proveedores de atención médica

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El Programa de Acceso

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PROGRAMA DE ACCESO DE MERCK

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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. 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 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 Co-pay Assistance 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 an annual maximum. The maximum Co-pay Assistance Program benefit per patient, per calendar year (January 1 through December 31), is $25,000.
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. 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, 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 Merck 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 date patient is enrolled in the Co-pay Assistance Program, subject to the annual Co-pay Assistance Program maximum and the applicable Terms and Conditions based on Program Product administration date. For clarity, out-of-pocket costs associated with a Program Product that was administered in the prior calendar year are NOT eligible for the benefit under the Co-pay Assistance Program for the current calendar year. 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 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, 2023, and December 31, 2023.
Expiration Date: 12/31/2023.

US-KEY-05894 10/22

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