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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


How to get NEXPLANON

Options for obtaining NEXPLANON

NEXPLANON is covered by most health care 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.


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.

1. Establish Account

Practice establishes an account with either CuraScript SD or TheraCom (specialty distributors)

2. Order Implant

Practice orders NEXPLANON

3. Benefit Investigation for Appropriate Patient

Once a patient and the HCP determine that NEXPLANON is appropriate, a benefit investigation is conducted either by the office or the Customer Support Center for NEXPLANON

4. Same-day Procedure Possible

If coverage is confirmed, the patient may receive NEXPLANON that day


5. Bill Insurance

Practice bills insurance carrier for procedure and implant

6. Payment

Practice pays invoice for NEXPLANON

Establish an account with one of our 2 specialty distributors

Ordering with CuraScript

You can order NEXPLANON by accessing a 90-day line of credit or using a credit card payment through your CuraScript SD account. Please check with the distributor for details and to confirm eligibility.

CURASCRIPT SD CALL CENTER

CuraScript SD has a dedicated team to support and assist you with online ordering for NEXPLANON.

Phone: 877-599-7748
Hours: Monday-Friday 8 AM-7 PM ET
Fax: 866-389-7928

Ordering with TheraCom

You can order NEXPLANON by accessing a 90-day line of credit or using a credit card payment. Please check with the distributor for details and to confirm eligibility.

THERACOM CALL CENTER

Phone: 866-318-3492
Hours: Monday-Friday 8 AM-8 PM ET
Fax: 866-769-3882

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

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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 between February 1, 2024, and October 31, 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 between February 1, 2024, and October 31, 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 between February 1, 2024, and October 31, 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 is 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
  • You may submit rebate requests through December 31, 2024, for claims dated between February 1, 2024, and October 31, 2024
  • 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

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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.

1. Benefit Investigation for Appropriate Patient

Once a patient and the HCP determine that NEXPLANON is appropriate, office submits the NEXPLANON enrollment form to the Customer Support Center (via fax or patient portal) to determine coverage. The enrollment form also serves as a prescription

2. Specialty Pharmacy Selection

If insurance plan allows for a pharmacy benefit option, prescription is triaged to the appropriate specialty pharmacy preferred by that plan

3. Bill Insurance for Implant

Specialty pharmacy will bill insurance plan for NEXPLANON and will ship patient-specific NEXPLANON to the office

4. Schedule Patient

Office schedules patient for procedure

5. Procedure

Patient returns to office for procedure

6. Bill Insurance for Procedure

Once procedure takes place, practice bills insurance carrier for procedure

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 health care 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.

Indication and Selected Safety Information

Indication

NEXPLANON is indicated for use by women to prevent pregnancy.

Selected Safety Information

CONTRAINDICATIONS

  • NEXPLANON should not be used in women who have known or suspected pregnancy; current or past history of thrombosis or thromboembolic disorders; liver tumors, benign or malignant, or active liver disease; undiagnosed abnormal genital bleeding; known or suspected breast cancer, personal history of breast cancer, or other progestin-sensitive cancer, now or in the past; and/or allergic reaction to any of the components of NEXPLANON.

WARNINGS AND PRECAUTIONS

Complications of Insertion and Removal

  • NEXPLANON should be inserted subdermally so that it will be palpable after insertion, and this should be confirmed by palpation immediately after insertion. Failure to insert NEXPLANON properly may go unnoticed unless it is palpated immediately after insertion. Undetected failure to insert the implant may lead to an unintended pregnancy. Failure to remove the implant may result in continued effects of etonogestrel, such as compromised fertility, ectopic pregnancy, or persistence or occurrence of a drug-related adverse event.
  • Complications related to insertion and removal procedures may occur, e.g., pain, paresthesia, bleeding, hematoma, scarring, or infection. If NEXPLANON is inserted deeply (intramuscular or intrafascial), neural or vascular injury may occur.
  • Postmarketing reports of implants located within the vessels of the arm and the pulmonary artery may have been related to deep insertions or intravascular insertions. Endovascular or surgical procedures may be needed for removal.
  • Implant removal may be difficult or impossible if the implant is not inserted correctly, inserted too deeply, not palpable, encased in fibrous tissue, or has migrated. If at any time the implant cannot be palpated, it should be localized and removal is recommended. When an implant is removed, it is important to remove it in its entirety. Failure to remove the implant may result in continued effects of etonogestrel, such as compromised fertility, ectopic pregnancy, or persistence or occurrence of a drug-related adverse event.

Broken or Bent Implants

  • Cases of breakage or bending of implants while inserted within a patient’s arm have been reported. Cases of migration of a broken implant fragment within the arm have also occurred. These cases may be related to external forces, e.g., manipulation of the implant or contact sports. The release rate of etonogestrel may be slightly increased in a broken or bent implant, based on in vitro data.

Changes in Menstrual Bleeding Patterns

  • After starting NEXPLANON, women are likely to have changes in their menstrual bleeding pattern. These may include changes in frequency, intensity, or duration. Abnormal bleeding should be evaluated as needed to exclude pathologic conditions or pregnancy. In clinical studies of the non-radiopaque etonogestrel implant, reports of changes in bleeding pattern were the most common reason for stopping treatment (11.1%). Women should be counseled regarding bleeding pattern changes that they may experience.

Ectopic Pregnancies

  • Be alert to the possibility of an ectopic pregnancy in women using NEXPLANON who become pregnant or complain of lower abdominal pain.

Thrombotic and Other Vascular Events

  • The use of combination hormonal contraceptives increases the risk of vascular events, including arterial events (strokes and myocardial infarctions) or deep venous thrombotic events (venous thromboembolism, deep venous thrombosis, retinal vein thrombosis, and pulmonary embolism). It is recommended that women with risk factors known to increase the risk of venous and arterial thromboembolism be carefully assessed. There have been postmarketing reports of serious arterial thrombotic and venous thromboembolic events, including cases of pulmonary emboli (some fatal), deep vein thrombosis, myocardial infarction, and strokes, in women using etonogestrel implants. NEXPLANON should be removed in the event of a thrombosis. Due to the risk of thromboembolism associated with pregnancy and immediately following delivery, NEXPLANON should not be used prior to 21 days postpartum. Women with a history of thromboembolic disorders should be made aware of the possibility of a recurrence. Consider removal of the NEXPLANON implant in case of long-term immobilization due to surgery or illness.

Ovarian Cysts

  • If follicular development occurs, atresia of the follicle is sometimes delayed, and the follicle may continue to grow beyond the size it would attain in a normal cycle. Generally, these enlarged follicles disappear spontaneously. Rarely, surgery may be required.

Carcinoma of the Breast and Reproductive Organs

  • Some studies suggest that the use of combination hormonal contraceptives might increase the incidence of breast cancer, and increase the risk of cervical cancer or intraepithelial neoplasia. Women with a family history of breast cancer or who develop breast nodules should be carefully monitored.

Liver Disease

  • NEXPLANON should be removed if jaundice occurs.

Elevated Blood Pressure

  • The NEXPLANON implant should be removed if blood pressure rises significantly and becomes uncontrolled.

Gallbladder Disease

  • Studies suggest a small increased relative risk of developing gallbladder disease among combination hormonal contraceptive users. It is not known whether a similar risk exists with progestin-only methods like NEXPLANON.

Carbohydrate and Lipid Metabolic Effects

  • Prediabetic and diabetic women using NEXPLANON should be carefully monitored.

Depressed Mood

  • Women with a history of depressed mood should be carefully observed. Consideration should be given to removing NEXPLANON in patients who become significantly depressed.

Return to Ovulation

  • In clinical trials with the non-radiopaque etonogestrel implant (IMPLANON), the etonogestrel levels in blood decreased below sensitivity of the assay by one week after removal of the implant. In addition, pregnancies were observed to occur as early as 7 to 14 days after removal. Therefore, a woman should re-start contraception immediately after removal of the implant if continued contraceptive protection is desired.

Fluid Retention

  • Hormonal contraceptives may cause some degree of fluid retention. They should be prescribed with caution, and only with careful monitoring, in patients with conditions which might be aggravated by fluid retention. It is unknown if NEXPLANON causes fluid retention.

Contact Lenses

  • Contact lens wearers who develop visual changes or changes in lens tolerance should be assessed by an ophthalmologist.

ADVERSE REACTIONS

Clinical Trial Experience

  • The most common adverse reaction causing discontinuation of use of the implant in clinical trials was change in menstrual bleeding patterns (11.1%). The most common adverse reactions (≥10%) reported in clinical trials were headache (24.9%), vaginitis (14.5%), weight increase (13.7%), acne (13.5%), breast pain (12.8%), abdominal pain (10.9%), and pharyngitis (10.5%).

DRUG INTERACTIONS

Effects of Other Drugs on Hormonal Contraceptives
Substances decreasing the plasma concentrations of hormonal contraceptives and potentially diminishing the efficacy of hormonal contraceptives:

  • Drugs or herbal products that induce certain enzymes, including cytochrome P450 3A4 (CYP3A4), may decrease the plasma concentrations of hormonal contraceptives and potentially diminish the effectiveness of hormonal contraceptives or increase breakthrough bleeding. Women should use an alternative non-hormonal method of contraception or a back-up method when enzyme inducers are used with hormonal contraceptives, and to continue back-up non-hormonal contraception for 28 days after discontinuing the enzyme inducer to ensure contraceptive reliability.

Substances increasing the plasma concentrations of hormonal contraceptives:

  • Co-administration of certain hormonal contraceptives and strong or moderate CYP3A4 inhibitors may increase the serum concentrations of progestins, including etonogestrel.

Human Immunodeficiency Virus (HIV)/Hepatitis C Virus (HCV) protease inhibitors and non-nucleoside reverse transcriptase inhibitors:

  • Significant changes (increase or decrease) in the plasma concentrations of progestin have been noted in cases of co-administration with HIV protease inhibitors, HCV protease inhibitors, or with non-nucleoside reverse transcriptase inhibitors. These changes may be clinically relevant.

Effects of Hormonal Contraceptives on Other Drugs

  • Hormonal contraceptives may affect the metabolism of other drugs. Consequently, plasma concentrations may either increase (for example, cyclosporine) or decrease (for example, lamotrigine).

USE IN SPECIFIC POPULATIONS
Pregnancy

  • Rule out pregnancy before inserting NEXPLANON.

Lactation

  • Small amounts of contraceptive steroids and/or metabolites, including etonogestrel are present in human milk. No significant adverse effects have been observed in the production or quality of breast milk, or on the physical and psychomotor development of breastfed infants.
  • Hormonal contraceptives, including etonogestrel, can reduce milk production in breastfeeding mothers. This is less likely to occur once breastfeeding is well-established; however, it can occur at any time in some women.

Pediatric Use

  • Safety and efficacy of NEXPLANON have been established in women of reproductive age and are expected to be the same for postpubertal adolescents. However, no studies have been conducted in women less than 18 years of age. Use of this product before menarche is not indicated.

Overweight Women

  • The efficacy of NEXPLANON in women who weighed more than 130% of their ideal body weight has not been defined because such women were not studied in clinical trials. Serum concentrations of etonogestrel are inversely related to body weight and decrease with time after implant insertion. Therefore, NEXPLANON may be less effective in overweight women.

PATIENT COUNSELING INFORMATION

  • Counsel women to contact their health care professional immediately if, at any time, they are unable to palpate the implant.
  • NEXPLANON does not protect against HIV or other STDs.

Before prescribing NEXPLANON, please read the accompanying Prescribing Information. The Patient Information also is available.

Indication

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Indication:

NEXPLANON is indicated for use by women to prevent pregnancy.

Selected Safety Information +

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Selected Safety Information:

NEXPLANON should not be used in women who have known or suspected pregnancy; current or past history of thrombosis or thromboembolic disorders; liver tumors, benign or malignant, or active liver disease; undiagnosed abnormal genital bleeding; known or suspected breast cancer, personal history of breast cancer, or other progestin-sensitive cancer, now or in the past; and/or allergic reaction to any of the components of NEXPLANON.

NEXPLANON should be inserted subdermally so that it will be palpable after insertion…