Important Instructions - CSCN
NEXPLANONsupport.com Other Required Fields for Completion Specialty pharmacy (SP) - you must select 1 SP that you prefer to use (Accredo Pharmacy, AllianceRx Walgreens Prime, Cigna Specialty Pharmacy
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PHONE: 844-NEX-4321 (844-639-4321) FAX: 844 …
www.merckcscn.comDIRECT SERVICE REQUEST FORM PHONE: 844-NEX-4321 (844-639-4321) FAX: 844-232-2618 Services Requested: n Benefit Investigation for NEXPLANON n Prescription Order Fulfillment Options: Specialty Pharmacy Order for Assignment of Benefits Only: n Accredo Pharmacy n AllianceRx Walgreens Prime n Cigna Specialty Pharmacy …
TO GET STARTED, COMPLETE THE ENROLLMENT FORM AND …
www.merckcscn.com2/3 Patient name: PATIENT AUTHORIZATION (continued) and any prescription for NEXPLANON® (etonogestrel implant) (my “PHI”). I authorize my physician, pharmacy(ies), and my health plan(s) to disclose my PHI to Lash as necessary to complete the insurance
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PHONE: 844-NEX-4321 (844-639-4321) FAX: 844 …
www.merckcscn.comDIRECT SERVICE REQUEST FORM PHONE: 844-NEX-4321 (844-639-4321) FAX: 844-232-2618 Services Requested: n Benefit Investigation for NEXPLANON n …
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