Important Instructions - CSCN

Benefit Investigation for NEXPLANON (No Prescription Order) Check the Benefit Investigation for NEXPLANON box. Select 1 Specialty Pharmacy (SP) under Fulfillment Options. Complete the entire form, including physician and patient signatures. The prescriber must sign twice, once above the Dispense as Written line and once on the Prescriber Signature line. Fax it to the Customer Support Center for NEXPLANON (CSCN). Confirmation of receipt of the Direct Service Request Form (DSRF) will be faxed to your office. Within 2 business days, your office will receive via fax the Benefit Summary Form describing the results of the benefit investigation.

Prescription Orders for NEXPLANON (no Benefit Investigation by the CSCN) If you do not want the CSCN to conduct a Benefit Investigation and only want CSCN to forward the prescription to the SP, only check the “Prescription

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