One form for all your needs The Service Request Form (SRF) allows you to request benefit verification and/or to place an order for IMPLANON®. You can fax the SRF to CVS at 1.866.769.3883 or call in your order to CVS at 1.866.318.3492.

CVS Caremark will always respond via fax to the prescriber/institution within 2 business days of receipt of the SRF.

Benefit verification

If you haven’t already verified your patient’s benefit information, CVS Caremark can help by completing this step for you. Simply fill in the patient insurance information portion of the SRF.

Please note that CVS Caremark does not make a guarantee of reimbursement or charge.

Prescription order

If IMPLANON^® is covered as a pharmacy benefit, or if your patient would like to pay cash, fill in the Prescription Information section of the SRF. Fax in both the form and the prescription.

Remember to send both sides of your patient’s insurance card when you fax in your order.

Buy and bill order

To order IMPLANON^® with the CVS 90-day payment terms, fill in the Buy and Bill section of the SRF. To pay by credit card, call the CVS support line.

Remember that the individual signing the SRF must be the trained clinician who will be inserting IMPLANON^®.

Delivery

IMPLANON^® is shipped via major carrier for two-day delivery. For next-day insertions, overnight delivery is available on request.

Questions?

Visit the FAQs page for more information about ordering with CVS Caremark.

Indication
IMPLANON^® (etonogestrel implant) is indicated for women for the prevention of pregnancy.

IMPLANON^® must be removed by the end of the third year and may be replaced by a new IMPLANON^® at the time of removal, if continued contraceptive protection is desired.


Important Safety Information

Women should be informed that this product does not protect against infection from HIV (the virus that causes AIDS) or other sexually transmitted diseases.

Serious consequences may be associated with the insertion and removal of IMPLANON^®. IMPLANON^® should be inserted subdermally so that it is palpable after insertion. Failure to insert IMPLANON^® properly may go unnoticed unless the implant is palpated immediately after insertion. Deep insertions may lead to difficult or impossible removals. Failure to remove IMPLANON^® may result in infertility, ectopic pregnancy, or inability to stop a drug-related adverse event. Undetected failure to insert IMPLANON^® may lead to an unintended pregnancy.

In clinical trials, 1.0% of patients had complications at implant insertion and 1.7% had complications at implant removal. Deep insertions may result in the need for a surgical procedure in an operating room in order to remove IMPLANON^®. When IMPLANON^® is inserted too deeply, this may cause neural or vascular damage. Too deep insertions have been associated with paraesthesia and migration of the implant and, in rare cases, with intravascular insertion. In postmarketing use, there have been cases of failure to localize and remove the implant, probably due to deep insertion. All healthcare providers performing insertions and/or removals of IMPLANON^® must receive instruction and training and, where appropriate, supervision prior to inserting or removing IMPLANON^®.

IMPLANON^® should not be used in women who have the following conditions: known or suspected pregnancy, current or past history of thrombosis or thromboembolic disorders, hepatic tumors (benign or malignant), active liver disease, undiagnosed abnormal genital bleeding, known or suspected carcinoma of the breast (or a personal history of breast cancer), or hypersensitivity to any of the components of IMPLANON^®.

Pregnancy must be excluded before inserting IMPLANON^®.

The use of IMPLANON^® and other progestin-only hormonal contraceptives have been associated with ectopic pregnancy, bleeding irregularities, and ovarian cysts. The use of hormonal contraceptives is associated with increased risks of several serious cardiovascular conditions including myocardial infarction, stroke, venous thromboembolism, deep venous thrombosis, retinal vein thrombosis, and pulmonary embolism. There have been postmarketing reports of serious thromboembolic events, including cases of pulmonary emboli (some fatal) and strokes, in patients using IMPLANON^®. IMPLANON^® should be removed in the event of a thrombosis. Consider removal of IMPLANON^® in case of long-term immobilization due to surgery or illness. Women with a history of thromboembolic disorders should be made aware of the possibility of a recurrence.

Cigarette smoking increases the risk of serious cardiovascular side effects from the use of hormonal contraceptives. This risk increases with age (women over 35 years of age) and with heavy smoking. Women who use hormonal contraceptives should be advised not to smoke.

In clinical trials including 942 patients, bleeding irregularities (11%) were the most common adverse event causing discontinuation of IMPLANON^®. Adverse events reported in >5% of subjects include headache, vaginitis, weight increase, acne, breast pain, upper respiratory tract infection, abdominal pain, pharyngitis, leukorrhea, influenza-like symptoms, dizziness, dysmenorrhea, back pain, emotional lability, nausea, pain, nervousness, sinusitis, depression, and insertion site pain.

Please see full Prescribing Information.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.