ONTRUZANT® (trastuzumab-dttb) Logo

Before prescribing ONTRUZANT, please read the accompanying
Prescribing Information, including the Boxed Warning about cardiomyopathy,
infusion reactions (pulmonary toxicity), and embryo-fetal toxicity.


RESOURCES

RESOURCES
Electronic Enrollment

The Merck Access Program 2020 Electronic Enrollment Form

This form can be signed and submitted electronically. Use this form only if the patient is in the office and you are able to complete the form together.

The Merck Access Program 2020 Electronic Health Care Provider Enrollment Form

This Health Care 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-ontruzant.com/hcc.

Enrollment

The Merck Access Program 2020 Enrollment Form

This form can be downloaded and printed, and requires an original signature.

The Merck Access Program Spanish Enrollment Form

The Merck Access Program Sample Enrollment Form

Representative’s Form

Potential Independent Foundation Support

Coverage and reimbursement support

Prior Authorization Checklist

Sample Prior Authorization Letter

Appeal Checklist

Sample Appeal Letter

Coding and billing resources

Electronic Billing Guide

Sample CMS-1500 Form

Sample UB-04 Form

Patient support materials

ONTRUZANT.com

Product information

Physician Prescribing 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.

You are solely responsible for determining the appropriate codes and for any action you take in billing. Information about HCPCS codes is based on guidance issued by the Centers for Medicare & Medicaid Services applicable to Medicare Part B and may not apply to other public or private payers. Consult the relevant manual and/or other guidelines for a description of each code to determine the appropriateness of a particular code and for information on additional codes. Diagnosis codes should be selected only by a health care professional.

Abbreviation: HCPCS, Healthcare Common Procedure Coding Systems.



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THE MERCK ACCESS PROGRAM

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