Enroll Now

Please review the enrollment options below to access The Organon Access Program and choose the method that best works for you and your patient. If your patient is requesting a referral to the Organon Patient Assistance Program, be sure to include all information, including a prescription for BILPREVDA, which you can now complete on the enrollment form. Please be sure all signatures are included prior to submitting forms to The Organon Access Program.

Electronic Enrollment
via CoverMyMeds

Allows health care providers to electronically enroll patients into The Organon Access Program and initiate other access services.

With CoverMyMeds, you can:

Perform benefits investigations and submit prior authorizations
Access the Organon Co-pay Assistance Program
Track patient case status
Submit prescriptions

Download & Print

Download this form to fill out, print, and fax

Download Enrollment Form

Patients can sign and submit the enrollment form electronically using DocuSign.
Looking for the DocuSign Provider and Patient Enrollment Form? Option 1 (Electronic Enrollment) replaced that form.
For help submitting that form via CoverMyMeds, call 855-459-9965.

Enrollment Assistance

Use this form as a guide for completing the enrollment form.

Sample Enrollment Form

Before prescribing BILPREVDA, please read the Prescribing Information.