Important Instructions - CSCN
Benefit Investigation for NEXPLANON (No Prescription Order) • Check the Benefit Investigation for NEXPLANON box. • Select 1 Specialty …
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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.comPatient Authorization (For benefit investigation request only) I understand that in order for Merck Sharp & Dohme B.V., a subsidiary of Merck & Co., Inc., and Lash (the company that will conduct reimbursement services on