Important Instructions - CSCN
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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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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www.merck.com1 FDA-Approved Patient Labeling NEXPLANON (etonogestrel implant) Radiopaque Subdermal Use Only NEXPLANON does not protect against HIV infection (the virus that causes AIDS) or other sexually transmitted diseases.
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www.merck.com1 HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use NEXPLANON safely and effectively. See full prescribing
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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