Direct Service Request Form and Important Instructions

The Direct Service Request Form is the first step in obtaining information about insurance coverage for NEXPLANON for your patient. Download the form below, complete it, and fax to the Customer Support Center for NEXPLANON (CSCN) to begin the benefit investigation process. Your benefit investigation will be completed within 2 business days after a completed form has been received.

If you have any questions about completing the Direct Service Request Form, please download and read the Important Instructions below or contact the CSCN directly.

Phone: (844) 639-4321
Fax: (844) 232-2618

When filling out this electronic Direct Service Request Form, please remember to:

  • Select a Specialty Pharmacy on your form.
  • Print the form after completing all required fields.
  • Ensure both the physician and patient sign the printed form.
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