Direct Service Request Form IMPLANON NEXPLANON

1 Direct Service Request FormPhone: 866-318-3492 Fax: 866-769-3882 Patient Benefit Verification and/or Prescription Order (For Patient Pharmacy Benefit) services Requested: q Benefit Verification q Prescription Order q Buy and bill PurchaseRequestedServicesPatientInformat ionPatientInsuranceInformationCopy and attach frontand back of insurancecard and prescriptiondrug cardLast Name: First Name: MI: DOB: SSN:Address: City: State: Zip Code: Phone: Alternative Phone: Primary Language:Prescription Drug Card: Medical Insurance: Phone: BIN.

2 Phone: PCN: Policy #: Group #: Policy #: Group #:Policy Holder Information (If different from patient)Name: Name:Employer: SS#: Employer: SS#:Relation to Patient: Relation to Patient:Patient has no insurance and/or does not want insurance billed.

3 Requests Self Pay option: q Single payment q 3-month payment planProduct: q NEXPLANON qIMPLANONP rescriberInformation( IMPLANON OR NEXPLANON -trained clinician)Prescriber Name (First, Last): Title: q MD q DO q NP q PAName of Practice:Office Contact: Phone: Fax:Address: City: State: Zip Code:Email: State Medical License #: Expiration Date:NPI #: Contact Preference: q Phone q Fax q EmailFor ARNP, NP & PA, collaborative physician agreement is with: Date.

4 PrescriptionInformation(Patient-Specific Orderfor specialty pharmacydispensing) Dispense 1 q Rx NEXPLANON (etonogestrel implant) 68 mg 1 q Rx IMPLANON (etonogestrel implant) 68 mg SIG: To be inserted one time by prescriber subdermallyProduct Substitution Permitted (signature) Date Dispense as written (signature) DateAllergies: Date of Last Menses: I certify that I have completed an IMPLANON training program if ordering IMPLANON , and that I have completed NEXPLANON training if ordering NEXPLANON .

5 If not certified, please contact your sales s Signature: Date:Notification: By submitting this prescription Request form , prescriber is aware that CVS Caremark will ship upon verification of benefits and collection of applicable copay. If there is a zero-dollar copay, patient will not be contacted. CVS Caremark will ship to prescriber s office, and will not contact prescriber before shipping. q q q q Other: PatientAuthorization(For benefit investigation Request only)I understand that in order for Caremark and Schering Corp.

6 (hereafter Merck ), a subsidiary of Merck & Co., Inc. to provide me with assistance, they will need to obtain, review, use and disclose my personal health information (PHI), including information relating to my medical condition and information on my Request form , and any prescription. I authorize my physician, pharmacy(ies) and my health plan(s) to disclose my PHI to Caremark and their administrators as necessary to complete the insurance investigation process. I further authorize Caremark and their administrators to use my PHI to provide services through this program, and to disclose the information to my health plan(s), and their contractors for the purpose of coordination of benefits, reimbursement support, investigating insurance coverage and to coordinate the delivery, receipt and storage of my IMPLANON or NEXPLANON prescription medication for the sole purpose of administration by my prescribing provider.

7 The prescribing provider listed below is my healthcare agent who administers IMPLANON or NEXPLANON at his/her medical agree to allow Caremark to contact me via mail, telephone, or email in connection with carrying out these services . I understand that my name, address, and any other personal identifying information provided in my Request form will be available to Caremark , and their affiliates. I understand that my PHI disclosed under this Request may no longer be protected by privacy laws and may be re-disclosed by Caremark only for the purposes described herein.

8 I also understand that non-identifiable information concerning individuals requesting assistance with insurance coverage may be summarized for statistical or other purposes and provided to Merck by Caremark , but my identity will not be determinable from such summary understand that if I don t provide an Authorization, I will not be able to obtain Service program assistance provided by Caremark, on behalf of Merck. I understand that I may cancel this Authorization at any time by mailing a written Request for such cancellation to my prescribing physician, pharmacy, health plans and Caremark , and the cancellation will not apply to any information already used or disclosed pursuant to this I don t cancel this Authorization, the Authorization will expire 15 months from the date signed below.

9 Merck has retained Caremark to provide services to customers, including reimbursement services . Information and questions related to the information provided in regard to this Request should be referred directly to Caremark Merck personnel are not aware of patient specific reimbursement information and are not permitted to discuss such information with customers. I have read this document or have had it explained to me. I understand that I may Request a copy of this Authorization once it has been signature: Date: / /Signature of legal representative (if applicable) Date: / / IMPLANON (etonogestrel implant) 68 mgNEXPLANON (etonogestrel implant) Fax to: 866-769-3882 Purchase of IMPLANON and/or NEXPLANON (Buy and bill )Provider will be invoiced for all products [ IMPLANON or NEXPLANON ] purchased from Caremark, at the rates quoted at the point-of-sale.

10 Provider is financially responsible for, and agrees to pay, Caremark, all invoiced charges for products ordered by Provider. Each invoice will be due and payable by Provider within the payment terms offered by Caremark, on the date-of-order. Signature.