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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. The CSCN staff will call your office to follow-up on the benefit investigation results. If there is coverage under the patient s pharmacy benefit, and you would like your prescription forwarded to the SP you selected under Fulfillment Options or to the SP required by the insurance plan, check the Prescription Order box on the DSRF and fax back to the 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 Services, CVS Health Pharmacy, Humana Health Pharmacy, or Magellan Rx Pharmacy).

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Transcription of Important Instructions - CSCN

1 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. The CSCN staff will call your office to follow-up on the benefit investigation results. If there is coverage under the patient s pharmacy benefit, and you would like your prescription forwarded to the SP you selected under Fulfillment Options or to the SP required by the insurance plan, check the Prescription Order box on the DSRF and fax back to the CSCN.

2 The CSCN will send a fax informing your office that the prescription has been sent to the SP required by the insurance plan if different from your preference. The SP will follow their standard business practices, which typically includes conducting their own benefit investigation before contacting your office regarding shipment. If coverage for the product is under the patient s medical benefit and you wish to place a Buy and Bill order, please contact your specialty Distributor (Curascript at 866-844-0148 or Theracom at 866-318-3492) directly. If you have questions regarding the Benefit Summary form, please contact your Reimbursement Support Counselor at the CSCN at Service Request Form (for Benefit Investigations and pharmacy Benefit orders) Service:Page 1 Important InstructionsWhen completing/submitting your Direct Service Request Form (Buy and Bill Order Form Instructions on last page)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 Order box.

3 Check only the Prescription Order box. Select 1 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 CSCN. The CSCN will send a fax informing your office that the prescription has been sent to the SP you selected under Fulfillment Options. The SP will follow their standard business practices, including conducting a benefit investigation and contacting your office regarding shipment. If you have questions regarding the Benefit Summary form, please contact your Reimbursement Support Counselor at the CSCN at Investigation for NEXPLANON and Prescription Order BoxesWhen both boxes are checked, a Benefit Investigation for NEXPLANON will be completed, and if coverage is available under the patient s pharmacy benefit, the prescription will be forwarded to the SP you selected under Fulfillment Options or to the SP required by the insurance plan.

4 Check both the Benefit Investigation for NEXPLANON and Prescription Order boxes. Select 1 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 CSCN. A confirmation of the receipt of the DSRF will be faxed back to your office. Within 2 business days, your office will receive via fax the Benefit Summary Form describing the results of the benefit investigation. If coverage is available under the patient s pharmacy benefit, the CSCN will send a fax informing your office that the prescription has been sent to the SP you selected under Fulfillment Options or the SP required by the insurance plan. The SP will follow their standard business practices, which typically includes conducting their own benefit investigation before contacting your office regarding shipment.

5 If you have questions regarding the Benefit Summary form, please contact your Reimbursement Support Counselor at the CSCN at Service Request Form (for Benefit Investigations and pharmacy Benefit orders) 2 Important InstructionsWhen completing/submitting your Direct Service Request Form (Buy and Bill Order Form Instructions on last page) Required Fields for CompletionSpecialty pharmacy (SP) - you must select 1 SP that you prefer to use (Accredo pharmacy , alliancerx walgreens prime , Cigna specialty pharmacy Services, CVS Health pharmacy , Humana Health pharmacy , or Magellan Rx pharmacy ). If the insurance plan requires a specific SP, the prescription will be sent to that SP. The CSCN will send a fax informing your office that the prescription has been sent to the SP required by the insurance plan if different from your selection under Fulfillment Options. Checking this box is required even for Benefit Investigations.

6 Prescriptions will only be forwarded if the Prescription Order box is also checked under Services Requested. Complete the Patient Information section. Complete the Patient Insurance Information section. You may write the medical and prescription benefit information into the DSRF or attach copies of both the medical and prescription benefit cards. You may also print this information from your Electronic Medical Record system as long as you add the patient s name and date of birth on each page of your printout. The CSCN will research both medical and pharmacy benefit coverage. If coverage is available under the patient s medical benefit, please call your specialty Distributor (Curascript at 866-844-0148 or Theracom at 866-318-3492) to purchase the product. If coverage is available under the patient s prescription benefit, and you would like to have the prescription filled, check the Prescription order box on the DSRF and fax it to the CSCN.

7 The prescription will be forwarded to the SP you selected under Fulfillment Options or to the SP required by the insurance patients with no insurance - If the patient has no insurance or does not want her insurance billed, check the Prescription Order box, select an SP under Fulfillment Options, complete the Patient Information section, check the Self Pay option in the Patient Insurance Information (do not provide any patient insurance information), and complete the Prescriber Information Section. The prescriber must sign twice, once on the Dispense as Written line and once on the Prescriber Signature line. The second signature is the clinician confirmation that he or she has been clinically trained on NEXPLANON. The SP will contact the patient for payment arrangements and contact your office to arrange the shipping date. Complete the Prescription Information section. This section must be completed to conduct a Benefit Investigation, including the Diagnosis Code information.

8 Anticipated Date of Insertion is not required but is helpful. The prescriber must be clinically trained on NEXPLANON. The prescriber must sign twice; once on the Dispense as Written line and once on the Prescriber Signature line. The second signature is the clinician confirmation that he or she has been clinically trained on NEXPLANON. Have your patient sign the Patient Signature line. The patient signature is required to fulfill the prescription when coverage is available under the patient s pharmacy benefit. In a few states and the District of Columbia (DC), minors may consent to their own medical care and therefore may sign the DSRF. These states and DC are listed on the first page of the Service Request Form (for Benefit Investigations and pharmacy Benefit orders)Page 3 Important InstructionsWhen completing/submitting your Direct Service Request Form (Buy and Bill Order Form Instructions on last page)Copyright 2018 Merck Sharp & Dohme , a subsidiary of Merck & Co.

9 , Inc. All rights reserved. WOMN-1046181-0089 05 Consent for Health Care and Contraceptive ServicesThere are no consistent state statutes, laws or guidance across all States regarding the ability of a minor to consent for their own health care and/or contraceptive services. Merck has conducted a review of the existing state statutes. Based on this review, the CSCN will process DSRF for benefit investigations for minors in the following: Alaska, Arkansas, California, Colorado, District of Columbia, Georgia, Hawaii, Idaho, Iowa, Kentucky, Maryland, Minnesota, North Carolina, New Mexico, Oregon, Tennessee, and Virginia. For all other states, clinicians must answer 1 of the 2 questions below from the first page of the DSRF:If your patient is a minor and is signing the authorization on the following page on her own behalf, please affirm that: This patient has the capacity to consent to treatment with NEXPLANON under the law of the state in which I practice [and the consent of a parent or guardian is not required]ORThis patient s parent or guardian has consented to the patient s treatment with NEXPLANON and has signed the DSRF on the second page under Patient Signature and has completed the Relationship to patient if signing on her behalf you as the clinician are unaware of the individual statutes or laws from your state, please check the second box on the first page of the DSRF and secure the signature of the patient s of TermsSpecialty pharmacy A designated pharmacy that dispenses specialty products.

10 Accredo pharmacy , alliancerx walgreens prime , Cigna specialty pharmacy Services, CVS Health pharmacy , Humana Health pharmacy , and Magellan Rx pharmacy are the 6 designated specialty Pharmacies for NEXPLANON. Accredo pharmacy , alliancerx walgreens prime , Cigna specialty pharmacy Services, CVS Health pharmacy , Humana Health pharmacy , and Magellan Rx pharmacy purchase NEXPLANON from Merck, ship it to the clinician, and bill the insurance company for NEXPLANON. A Benefit Investigation conducted by the CSCN will provide available insurance benefit coverage prior to product being shipped. This ordering process is commonly known as Assignment of Benefits. specialty Distributor A designated specialty distributor that purchases specialty products. Curascript and Theracom are the 2 designated specialty Distributors for NEXPLANON. Curascript and Theracom purchase NEXPLANON from Merck. Clinicians order NEXPLANON from Curascript or Theracom.


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