Ordering & Billing

Ordering & Billing Codes for
NEXPLANON^® (etonogestrel implant) 68 mg Radiopaque

Select any of the topics below to jump to specific Ordering & Billing sections

Specialty distributors Rebate Program Replacement Program Specialty pharmacy CSCN Possible billing codes

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How to get NEXPLANON

Options for obtaining NEXPLANON

NEXPLANON is covered by most healthcare plans. If covered, NEXPLANON will be covered as either a medical benefit or a pharmacy benefit.

Verify each patient’s insurance coverage

Insurance coverage varies from patient to patient. It is important to know what coverage the patient has before NEXPLANON is purchased.

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Specialty distributors/buy and bill

This is the most common form of coverage for NEXPLANON. It means that both the drug and procedure are covered under the same benefit. A practice may purchase NEXPLANON from specialty distributors to maintain an in-office inventory.

These graphics denote a typical process for procurement. Procurement processes are subject to change. Contact your preferred procurement provider for a complete overview of the current procurement process.

Establish an account with one of our 2 specialty distributors

A 2% prompt pay discount is available under both the CuraScript SD and TheraCom specialty distributors for eligible customers.

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Commercial Coverage Assurance Program for NEXPLANON

Rebate Request

This program is intended to help customers who are reimbursed less than their acquisition cost for NEXPLANON on eligible patient claims for dates of service on or after February 1, 2024.

• To be eligible, you must have purchased NEXPLANON at the wholesale acquisition cost (WAC), not at a manufacturer discounted or contracted price.
• In addition, only patient claims under commercial insurance plans are eligible for this program.
• This program does not apply to patient claims or reimbursement received from state or federal healthcare programs, including Medicaid, Managed Medicaid, Medicare, or TRICARE.

If your request meets all the criteria set forth below, you will receive a rebate check for the difference between (1) the total reimbursement amount you received for that unit from the plan and from patient cost sharing amounts and (2) the acquisition cost for NEXPLANON. The maximum amount of the rebate check is $200 per claim.

To request a rebate, you are required to submit the following documentation:

• Completed Rebate Request Form, either via fax or email, found here:

• Invoice from your distributor showing the price paid for NEXPLANON (invoice must be dated on or after February 1, 2024)
• An Explanation of Benefits (EOB) with the amount paid by the insurance plan for the unit. PLEASE REMOVE/BLACKOUT ALL PATIENT INFORMATION AND PATIENT HEALTH INFORMATION (PHI) TO MAINTAIN HIPAA COMPLIANCE. The patient date of service/insertion must be on or after February 1, 2024

For any questions about the program, please call 800-561-5484 between 8 AM and 5 PM ET.

Additional program terms and conditions:

• NEXPLANON must have been administered in the United States
• If any data are missing from your Request Form, a representative from Organon’s service provider, HCL, will reach out to you to obtain that information
• If your request does not meet the requirements above, you will receive an email notifying you that your claim was denied and the reason for the denial
• If your claim meets all criteria, a check will be mailed to the address listed on the Request Form
• Rebate Request Form must be submitted within 1 year of the insertion date for the implant that was under-reimbursed
• Request Form must contain an original customer signature 
• Organon reserves the right to amend or terminate this program at any time without notice
• Customers receiving rebates under this program must comply with all federal and state healthcare reporting and disclosure rules for discounts and rebates
• Upon approval of your request, you may not seek further reimbursement from the plan or patient for the rebated units
• If a patient has more than one insurance plan, please provide the EOBs for all plans where reimbursement was requested or received. If you are eligible for a rebate, the rebate amount will be equal to the difference between your acquisition price and the total reimbursement from all commercial insurance plans. You will not be eligible for this program if any of the plans are state or federal healthcare programs, including Medicaid, Managed Medicaid, Medicare, or TRICARE

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Replacement Request

Following insertion, if your patient has been denied coverage by their plan, use this form to apply for a replacement NEXPLANON at no cost for any insertions performed on February 1, 2024, or later which were subsequently denied as shown on the Explanation of Benefits (EOB). This program is valid for US patients with commercial insurance only.

This program is intended to help customers who experience insurance coverage denials for eligible NEXPLANON claims for dates of service on or after February 1, 2024. To be eligible, patients must have private health insurance at the time NEXPLANON is administered, and you must have sought coverage from the private health insurer for NEXPLANON, demonstrated by providing an Explanation of Benefits (EOB). This program does not apply to patient claims or reimbursement received from state or federal healthcare programs, including Medicaid, Managed Medicaid, Medicare, or TRICARE. The maximum number of replacements issued each calendar year is 5 per healthcare provider (HCP) per insurance plan. If your request meets all the criteria set forth, you will receive a replacement NEXPLANON implant at no cost.

To request a product replacement under this program for NEXPLANON, you are required to submit the following documentation:

• A completed Replacement Request Form either via fax or email, found here:

• An Explanation of Benefits (EOB) from a private health insurance plan showing complete coverage denial for NEXPLANON units that were inserted on or after February 1, 2024. PLEASE REMOVE/BLACKOUT ALL PATIENT INFORMATION AND PATIENT HEALTH INFORMATION (PHI) TO MAINTAIN HIPAA COMPLIANCE. The patient date of service/insertion must be on or after February 1, 2024
  • In the case of partial reimbursement from a commercial plan, you may be eligible to submit a Rebate Request instead. Please refer to the Rebate Request details above

For any questions about the program, please call 800-561-5484 between the hours of 8 AM and 5 PM ET.

Additional program terms and conditions:

• NEXPLANON must have been administered in the United States
• Replacement Request Form must be submitted within 1 year of the insertion date for the implant that was denied coverage
• If any data are missing from your Request Form, a representative from Organon’s service provider, HCL, will reach out to you to obtain that information
• If your request does not meet the requirements above, you will receive an email notifying you that your claim was denied and the reason for the denial
• Request Form must contain an original customer signature
• If your claim meets all criteria, a replacement NEXPLANON implant will be shipped to the address listed on the Request Form
• Organon reserves the right to amend or terminate this program at any time without notice
• Upon approval of your request, you may not seek further reimbursement from the plan or patient for the replaced units
• If a patient has more than one insurance plan, please provide the EOBs for all plans where reimbursement was requested or received. To be eligible for a replacement, all EOBs must show $0 reimbursement. You will not be eligible for this program if any of the plans are state or federal healthcare programs, including Medicaid, Managed Medicaid, Medicare, or TRICARE

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Specialty pharmacy

This is the less common form of coverage for NEXPLANON. It means that the drug is covered separately from the procedure.

After the pharmacy benefit is determined, a specialty pharmacy can deliver NEXPLANON to the practice.

These graphics denote a typical process for procurement. Procurement processes are subject to change. Contact your preferred procurement provider for a complete overview of the current procurement process.

Our specialty pharmacy network

Accredo Pharmacy
866-844-0148

CVS Specialty Pharmacy
800-237-2767

AllianceRx Walgreens Pharmacy
888-380-6188

CenterWell Pharmacy
800-486-2668

ASPN Pharmacies, LLC
888-970-0195

Magellan Rx Pharmacy
866-554-2673

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The Customer Support Center for NEXPLANON (CSCN)

CSCN may be able to help answer questions about:

• Patient benefit investigations
• Possible billing codes for insertion and removal
• Fulfillment of pharmacy prescription orders

How to enroll

You can fill out and submit the form using our online portal

There is also the option to download, print, complete, and fax the form

Additional resources

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

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Possible billing codes

To accurately bill and obtain reimbursement, it’s important for you to know which billing codes to use to describe NEXPLANON and any procedures related to it.

The codes listed below may be relevant when billing for NEXPLANON and its insertion or removal. The information available here is compiled from sources believed to be accurate, but Organon makes no representation that it is accurate. This information is subject to change. Payer coding requirements may vary or change over time, so it is important to regularly check with each payer as to payer-specific requirements.

The information available here is not intended to be conclusive or exhaustive, and is not intended to replace the guidance of a qualified professional advisor. Organon and its agents make no warranties or guarantees, expressed or implied, concerning the accuracy or appropriateness of this information for your particular use given the frequent changes in public and private payer billing. The use of this information does not guarantee payment or that any payment received will cover your costs.

You are solely responsible for determining the appropriate codes and for any action you take in billing. Diagnosis codes should be selected only by a healthcare professional, and should appropriately reflect the diagnosis, the services rendered, and the applicable payer’s guidelines.

Consult the relevant manual and other guidelines for a description of each code to determine the appropriateness of a particular code and for information on additional codes.

Billing codes

Please note: Other codes may also be appropriate for NEXPLANON; consult the ICD-10-CM Manual to check the appropriateness of a particular code and for information on additional codes.

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Definitions

CPT = Current Procedural Terminology. CPT Copyright 2017 American Medical Association. All rights reserved.
CPT^® is a registered trademark of the American Medical Association. CPT 2018 Professional Edition. Chicago, Ill: American Medical Association, 2017.

ICD-10 = International Classification of Diseases, Tenth Revision, Clinical Modification. National Center for Health Statistics, Centers for Disease Control and Prevention. FY 2018 ICD-10-CM. Available at: https://www.cdc.gov/nchs/icd/icd-10-cm.htm.

J-code = J-codes are part of the Healthcare Common Procedure Coding System (HCPCS). Centers for Medicare and Medicaid Services. 2018 Alpha-Numeric HCPCS File. Available at: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS-Items/2018-Alpha-Numeric-HCPCS-File-.html.

CSCN = Customer Support Center for NEXPLANON; HCP = healthcare professional; NDC = National Drug Code.