With the Paragard Specialty Pharmacy SM program, . You can count on our guidance, education, and compassion throughout your entire course of treatment. Select your specialty therapy, then download and complete the appropriate enrollment form when you send us your prescription. ParaGard Direct 3101 Gaylord Parkway Frisco, TX 75034 1-877- ParaGard (727-2427) phone 1-800-299-8332 fax Give us your feedback: contact us. Pharmacy Method (cont.) Sign, fax and printable from PC, iPad, tablet or mobile with pdfFiller Instantly. IMPORTANT SAFETY INFORMATION CONTRAINDICATIONS The use of Paragard is contraindicated when one or more of the following conditions exist: Product Quality: . I understand that my signature will be used as an approval allowing the Specialty Pharmacy to dispense Paragard. Note: RHOGA *EXCEPTIONS APPLY. Request for DME (lancets, strips, monitor) is a covered benefit (no auth required if limit is not exceeded) check The Medicines360 LNG-IUS is available through Accredo Specialty Pharmacy. Using electronic prior authorization (ePA) in the electronic health record or by visiting CoverMyMeds or ExpressPAth. FORTEO (teriparatide injection) can help reduce your risk of having another fracture. Search for brand and generic medications by condition, or download the CVS Specialty drug list as a PDF. Effective, February 1, 2013, all participating Hematologists and Oncologists will be required to receive prior authorization before administering injectable drugs with costs over $250. Depending on a patient's insurance plan, offices can order Mirena through a Specialty Pharmacy. Open PDF, opens in a new tab or window. Please note that invoice remaining balances may not be reflecting correctly due to recent upgrades to our systems. The remaining share of the cost is billed by the Specialty Pharmacy. Company Information For more product information please visit www.paragard.com. ePA and ePrescription. . Texas Commercial Health Plan - SP Alignment. Your office may find it useful to use it at the same time you are checking the office visit copay or procedure coverage. Fax the completed request form to: Non-Specialty 1-888-836-0730 or Specialty 1-866-249-6155. This Benefits Verification Worksheet can be used to document and track a patient's insurance benefits. . 801622EPF060616 22. Office of Pharmacy Affairs Health Resources and Services Administration 5600 Fishers Lane, 08W05A Rockville, MD 20857. 2014 Teva Women's Health, Inc. PAR-40229 February 2014 ; This offer is not valid for patients enrolled in Medicare, Medicaid, or other federal or state healthcare programs . Mirena (levonorgestrel-releasing intrauterine system) 52 mg is indicated for prevention of pregnancy for up to 8 years; replace after the end of the eighth year. SPECIALTY PHARMACY; RESOURCES; The Customer Support Center for NEXPLANON (CSCN) may be able to help answer questions about: . Download our Specialty Pharmacy Request Form; Complete the form and fax it back to your chosen specialty pharmacy; Paragard Specialty Pharmacy Partners. This specialty pharmacy may contact you regarding Paragard, or you may contact them . Resources . Ordering specialty drugs is easy . Optum Specialty Pharmacy. Business Records Affidavit. The system should be replaced after 6 years if continued use is desired. Texas . Bayer offers a patient assistance program that provides Kyleena, Mirena and Skyla Intrauterine Devices at no cost for eligible patients. Patient Referral Form PARAGARD Access Solutions Benefits Verification G) WEB: PARAGARDAccessSolutions,corn PHONE: 1-888-275-8596 FAM-855-215-5315 PAR Specialty Pharmacy Patient Direct Service Requested PARAGARD Benefits VerificationS'* PARAGARD Specialty PharmacySM PARAGARD Patient DirectTM (Patient Self-Pay) ICD-IO Coding request form for LARC to the specialty pharmacy Patient returns at a later date for LARC insertion 13. . All forms are printable and downloadable. Please contact 1-855-LILETTA (1.855.545.3882) to place a buy and bill order for office stock. With this service, your patient's prescription for Paragard is fulfilled through Biologics specialty pharmacy and shipped directly to your office. These may include changes in frequency, intensity, or duration. Specialty Pharmacy. Enter the patient and prescriber information in the space provided on the Specialty Pharmacy Prescription Request Form, including the patient's pharmacy drug can withdraw (ie, take back) this authorization earlier by sending a written request to Bayer Healthcare Pharmaceuticals, Attn: Medical Communications, 100 Bayer Boulevard, Whippany, NJ 07981 (Fax# 973-305-3560), except to the extent my healthcare provider or health plan has taken action in reliance on my authorization. Extra 20% off $60+ with code EXTRA20 Endovascular or surgical procedures may be needed for removal. prescriber is This informa on is intended only for the use of the individual or en ty named . directly if you have any questions. Skyla may go into or go through the uterus and cause other problems. WHC Support Center Forms. (Walgreens Specialty Pharmacy) . Fill out the required fields which are yellow-colored. Specialty Pharmacy. ASD Account Setup Initiation. Rebate Reimbursement Request Form. Bleeding and spotting may increase in the first 3 to 6 months and remain irregular. www.navitus.com www.txvendordrug.com 801622EPF060616 23 . Contact the 340B Prime Vendor Program. Your healthcare provider has ordered Paragard through the following specialty pharmacy. If drugs are administered without authorization, the claim will be denied and the provider will not receive payment. You may also call our direct Medical Information line at: 1.800.678.1605 . Title: _Paraguard.pdf Author: Crystal Leslie Created Date: 1/3/2022 1:55:02 PM Select Specialty Pharmacy. If I have a financial responsibility for obtaining Paragard, I understand that Biologics will contact me prior to the dispense. Mental Health Refill Shipment Request Form. Fax your prescription to 1-800-323-2445. Specialty pharmaceuticals: are used in the management of specific chronic or genetic conditions are often injectable or infused medicines, but may also include oral medicines require additional education of the member and close monitoring of their clinical response in collaboration with their doctor Synagis Order Form. Statement of Medical Necessity Cover Letter Template . There are several ways to submit it: Calling our Pharmacy Services Center at 888-261-1756. Open the document in the full-fledged online editor by clicking Get form. Specialty Pharmacy. Paragard Specialty Pharmacy Request Form (Digital) - Read online for free. Intrauterine System (IUS) WAC Price Information - HCP/Office Manager . Note that some insurers may require use of a particular specialty pharmacy. Walgreens. Get 24/7 Support. Paragard (NDC 51285020401) Biologics, Inc, Specialty Pharmacy c/o TWH Access Solutions In order for the Specialty Pharmacy to ship my prescription medication for NEXPLANON directly to my prescribing provider, I authorize the Specialty Contact Information Provider Relations Department I understand that my signature will be used as an approval allowing the Specialty Pharmacy to dispense Paragard. By submitting this Service Request Form. Specialty Pharmacies may be able to bill the insurance company directly for Mirena. Patient benefit investigations; Possible billing codes for insertion and removal; Fulfillment of pharmacy prescription orders; 2 WAYS TO ENROLL. 340B News; Manufacturer Updates SP Patient Reminder Form. . Select Specialty Pharmacy. If an approval is needed, you or the pharmacy needs to contact us with that request. Form, Long Acting Reversible Contraception (LARC) . Phone : 1 (800) 294-5979. PATIENT INSURANCE INFORMATION (Please copy and attach the front and back of medical and prescription insurance cards - Send with request) GET STARTED com PHONE 1-888-275-8596 Specialty Pharmacy FAX 1-855-215-5315 Bene t Veri cation SM Patient Referral Form Service Requested Specialty PharmacySM Benefits VerificationSM Patient DirectTM . Providers should complete the Specialty Pharmacy Prescription Request form and include patient authorization when sending the completed form to the chosen pharmacy distributor. Specialty Pharmacy Enrollment Form. *Please note that while Bayer provides the Kyleena IUD, Mirena IUD, and Skyla IUD at no cost to patients, the patient may still have a deductible, co-pay or incur other charges (i.e. To order Kyleena, Mirena or Skyla, complete the Specialty Pharmacy Prescription Request Form as follows: 1. Specialty Pharmacy SPECIALTY PHARMACY (Choose one) Biologics by McKesson City Drugs - A BioMatrix Specialty Pharmacy Fax 1-855-215-5315 1-212-988-4501 Phone 1-888-275-8596 1-855-988-4500 Hours of Operation Mon-Fri 9:00 AM - 6:00 PM ET Mon-Fri 9:00 AM - 7:00 PM ET Sat 9:00 AM - 3:00 PM ET Complete the form, then fax pages 1 and 2 to your . Biologics by McKesson. We offer access to specialty medications and infusion therapies, centralized intake and benefits verification, and prior authorization assistance. After starting NEXPLANON, women are likely to have changes in their menstrual bleeding pattern. SPECIALTY PHARMACY NOTIFICATION: By submitting this prescription request form and checking the Specialty Pharmacy box above, prescriber and patient are aware that Biologics, Inc. will ship upon verification of benefits and collection of applicable copay. REQUEST FORM PHONE: 844-NEX-4321 (844-639-4321) FAX: 844-232-2618 Services Requested: Fulfillment Options: . ET) apexusanswers@340bpvp.com. . Ovarian cysts may occur but usually disappear. FORTEO is a prescription medicine used to treat postmenopausal women who have osteoporosis who are at high risk for having broken bones (fractures) or who cannot use other osteoporosis treatments. . WEB ParagardAccessSolutions. Ordering and Reimbursement for Kyleena, Mirena, and Skyla . 2. Pregnancy while using Skyla is uncommon but can be life threatening and may result in loss of pregnancy or fertility. Put the date. Enter the patient and prescriber information in the space provided on the Specialty Pharmacy Prescription Request Form, including the patient's pharmacy drug benefit and medical insurance information. The document(s) accompanying this transmission may contain conden al health informa on that is legally privileged. SPECIALTY PHARMACY ORDER FOR ASSIGNMENT OF BENEFITS ONLY: Please select one fulfillment option to indicate your preference. Birth control We also offer infusion services with Optum Infusion Pharmacy. Find out if your medication is available through CVS Specialty. CVS Caremark maintains the Preferred Drug list (also known as a Formulary), manages a network of retail pharmacies and operates Mail Service and Specialty Drug pharmacies. alliancerxwp.com *. Call us at 1-800-237-2767. In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. The Benets Verication Request Form form is 2 pages long and contains: 0 signatures; 6 check-boxes; . You can order your specialty drugs through AllianceRx Walgreens Pharmacy, and your medication will arrive right at your home. Biologics by McKesson City Drugs. insertion/removal fees). Choose the document or form you need to continue: Specialty Pharmacy Request Form Use our library of forms to quickly fill and sign your Paragard IUD forms online. FORTEO can lessen the chance of broken bones (fractures) in . Type: Hormonal (estrogen and progestin) Method: Flexible rings are inserted by you into your vagina, once per month. Patient name: o LU I . Starting on January 1, 2022, the secure portal will give pharmacy providers, prescribers and their staff access to the Prior Authorization (PA) system; beneficiary drug look-up tool; and web . CVS Specialty dispenses a wide array of specialty medication used to treat many health conditions. information on my request form, CUSTOMER SUPPORT CENTER PHONE: 844 -NEX-4321 (844-639-4321} FAX: 844-232-2618. We are working to correct the issue, however if you need confirmation of your invoice balance please contact our Accounts Receivable team at 877-727-2427 Option 1 or by email at ParagardAR@icsconnect.com. Enter the patient and prescriber information in the space provided on the Specialty Pharmacy Prescription Request Form, including the patient's pharmacy drug benefit and medical insurance information. Powerful and sophisticated, yet delightfully simple Fill Fill makes it super easy to complete your PDF form. Mail the completed request form to: Aetna Pharmacy Management 1300 East Campbell Road Richardson, TX 75081 Pharmacy and Therapeutics (P&T) committee The services of an independent National Pharmacy and

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