paragard access center · top navigation bar and select “view recurring payments.” click “add...

PARAGARD Access CenterMaking access easier for your patients who choose PARAGARD.

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Table of Contents

Welcome to PARAGARD Access Center ........................................................................................................ 3About This Guide .............................................................................................................................................. 4We’re Here to Help ........................................................................................................................................... 5

PARAGARD Direct™ .......................................................................................................................................... 7 Quick Start Guide ............................................................................................................................................ 9 Getting Started ................................................................................................................................................. 11 Placing an Order ............................................................................................................................................... 13 Using the Online Payment Center ..................................................................................................................... 16 PARAGARD Direct™ Forms .............................................................................................................................. 22 Frequently Asked Questions ............................................................................................................................. 23

PARAGARD Benefits VerificationSM .................................................................................................................. 25 Quick Start Guide ............................................................................................................................................. 27 Getting Started ................................................................................................................................................. 29 PARAGARD Benefits VerificationSM Forms .......................................................................................................... 33 Patient Authorization Electronic Signature Instructions ...................................................................................... 34 Frequently Asked Questions ............................................................................................................................. 36

PARAGARD Specialty PharmacySM .................................................................................................................. 37 Quick Start Guide ............................................................................................................................................. 39 Getting Started ................................................................................................................................................. 41

PARAGARD Specialty PharmacySM Forms ......................................................................................................... 44 Frequently Asked Questions ............................................................................................................................. 46

PARAGARD Patient Direct™ ............................................................................................................................. 47 Quick Start Guide ............................................................................................................................................. 49 Getting Started ................................................................................................................................................. 51 PARAGARD Patient Direct™ Forms ................................................................................................................... 54 Frequently Asked Questions ............................................................................................................................. 56

Welcome to PARAGARD Access Center

We developed PARAGARD Access Center with you and your patients in mind, as part of our commitment to providing options that allow your appropriate patients to obtain PARAGARD. PARAGARD Access Center provides a comprehensive range of support services and resources designed to make access easier for your patients who choose PARAGARD.

Our “buy and bill” option that makes ordering PARAGARD fast and easy. With PARAGARD Direct™, you can place orders online, by fax, or over the phone, and take advantage of Volume Discount pricing.

Designed to provide benefits information on each patient’s insurance coverage for PARAGARD. With this service, you can request a Benefits Verification Report and receive patient-specific coverage information, including reimbursement amounts when available.

With this service, your patient’s prescription for PARAGARD is fulfilled through our Specialty Pharmacy and shipped directly to your office. The Specialty Pharmacy will also process the claim with your patient’s health insurer and collect any applicable co-pay for the unit.

A solution for patients who choose to self-pay for PARAGARD. PARAGARD Patient Direct™ allows patients who have a prescription for PARAGARD to order the unit and have it sent to your office for placement.

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About This Guide

This guide is intended to provide you with everything you need to know about each of our PARAGARD Access Center services. Each section starts with a Quick Start Guide designed to get you the information you need as quickly as possible. You’ll also find more detailed step-by-step instructions that will guide you through the process for each service.

Information SecurityThe confidentiality of information within PARAGARD Access Center websites is safeguarded to protect your patients’ electronic health information. These websites use a secure authentication process to ensure that users may only view the level of information permitted by their access privileges.

PARAGARDAccessCenter.com

Visit PARAGARDAccessCenter.com to get started or learn more about our service options.

We’re Here to Help

If you have any questions about PARAGARD Access Center services, please speak with your PARAGARD Sales Representative, visit us online at PARAGARDAccessCenter.com, or call 1-877-PARAGARD.

My PARAGARD Sales Representative is and may be reached at:

Phone:

Email:

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PARAGARD Direct™

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PARAGARD Direct™ is our “buy and bill” option that makes ordering PARAGARD fast and easy. With PARAGARD Direct™, you can place orders online, by fax, or over the phone, and take advantage of Volume Discount Pricing.

WEB: PARAGARDDirect.comPHONE: 1-877-PARAGARD (option 1)

ADDRESS: 3101 Gaylord Pkwy, Frisco, TX 75034

Existing Accounts:

FAX: 1-800-299-8332

EMAIL: [email protected]

New Accounts:

FAX: 1-469-365-8168


To set up your account:

Online:1. Visit PARAGARDDirect.com.2. Click “Account Sign Up.”3. Complete and submit the PARAGARD Direct™ Business Application and the

Letter of Affiliation e-sign forms.4. Email or fax a copy of your medical license to [email protected]

or 1-469-365-8168.

By phone:1. Call 1-877-PARAGARD and select option 1.2. One of our Specialists will walk you through this simple process.

To place an order:

Online:1. Visit PARAGARDDirect.com and log in.2. On the left-hand navigation, click “Order Products.”3. Update the “Basket Qty” to the desired quantity.4. Click “Checkout.”

By phone:1. Call 1-877-PARAGARD and select option 1.2. Have your account number ready and one of our Specialists will be happy to assist

in placing your order.

By email or fax:1. Visit PARAGARDDirect.com.2. On the top navigation, click “Forms.”3. Complete the PARAGARD Direct™ Order Form.4. Email the order form (or purchase order) to [email protected]

or fax it to 1-800-299-8332.

Quick Start Guide

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To pay your bill:

1. Visit PARAGARDDirect.com and log in.2. On the left-hand navigation, click “Online Payment Center.”3. On the top navigation, click “Bills.”4. Select the bill(s) you wish to pay.5. Click “Pay Selected.”6. Complete the payment information and click “Submit.”

To check the status of your order:

1. Visit PARAGARDDirect.com and log in.2. On the left-hand navigation, click “Reports.”3. Select the “Order Status” report.4. Click on the “Sales Order Number” of the order status you wish to check.5. The status can be found in the “Status” column.

Volume Discount Program

You may be eligible to receive volume-based discounts on your orders through PARAGARD Direct™. Ask your PARAGARD Sales Representative or a PARAGARD Direct™ Specialist for more details.

Looking for more quick tips for using PARAGARD Direct™? Please go to page 23 for Frequently Asked Questions.

Setting up your PARAGARD Direct™ account

To use PARAGARD Direct™, you must first set up your account. We recommend going online for fast account setup, but you can also set up your account over the phone.

To set up your account online: 1. Visit PARAGARDDirect.com.2. Click “Account Sign Up.”3. Complete and submit the PARAGARD Direct™ Business Application and the

Letter of Affiliation e-sign forms.4. Email or fax a copy of your medical license to [email protected]

or 1-469-365-8168.

Getting Started

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To set up your account over the phone: 1. Call 1-877-PARAGARD (727-2427) and select option 1.2. A PARAGARD Direct™ Specialist will complete the appropriate forms for you and send them back

for your signature.3. Review and sign the forms and email or fax them back with a copy of your medical license to

[email protected] or 1-469-365-8168.

Setting up your PARAGARD Direct™ online account

1. Visit PARAGARDDirect.com.2. Click “Account Sign Up.”3. Scroll down to “Existing Accounts Online Registration.”4. Complete the required fields and click “Submit.”

Note: Please list all account numbers that need access. Account numbers can be found in the email you receive once the account is set up.

Your online account will be ready in 1-2 business days.

Placing an Order

To place an order online:1. Visit PARAGARDDirect.com and log in.2. On the left-hand navigation, click “Order Products.”3. Update the “Basket Qty” to the desired quantity and click “Checkout.”4. On the Checkout page, verify that your shipping address and order quantity are correct.

• If your shipping address is incorrect, click “Update here,” input your correct address, then click“Send Address Change.” Please Note: PARAGARD Direct™ will need to reach out to you andvalidate your new address before your order can be shipped

• If you would like to change the quantity of your order, click “Change Order”5. Select one of the following options for checkout:

• Click “Pay Now” to pay by credit card or eCheck. Then click “Submit Payment & Order.”If approved, the funds will be deducted from your account immediatelyor

• Click “Submit Order” to use your line of credit or pre-pay account

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When your order is processed, you will receive shipping and delivery notifications at your preferred method of contact.

Place an order by phone:

1. Call 1-877-PARAGARD and select option 1.2. Have your account number ready and one of our Specialists will be happy to assist you in placing

your order.

Place an order by fax or email:

1. Visit PARAGARDDirect.com.2. On the top navigation, click “Forms.”3. Complete the PARAGARD Direct™ order form.4. Email the form (or purchase order) to [email protected] or fax it to 1-800-299-8332.

PARAGARD Direct™ cannot ship any orders without a current, valid state medical license on file, so it’s important to keep us up to date with your current licenses in order to prevent shipping delays.

To update your account, please submit a Letter of Affiliation e-sign form and send a copy of your updated license to:

FAX: 1-800-299-8332


!

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Using the Online Payment Center

Our Online Payment Center allows you to fully manage your account online. Here you can view and pay your bills, view payment history, and manage account and payment information. To visit the Online Payment Center, log in and click “Online Payment Center” on the left-hand navigation.

View and Sort Bills

You can use the provided filters to narrow down your search and sort the order of your bills. To view and sort your bills, choose “Bills” on the top navigation bar. You may sort by:

• Viewed• Unviewed• Paid• Unpaid• Account #

Filing Bills

Filing bills is optional and may be used to help manage the number of bills that display in your bill history.

To file a bill:1. Select the bill(s) you’d like to file.2. Click “File Selected.”

To view filed bills:1. Hover over “Bills” on the top navigation bar

and select “View Filed Bills.”

Pay Bills

You can pay just one or multiple bills at a time through our online payment center. Choose “Bills” on the top navigation bar. To pay bills:

1. Select the bill(s) you wish to pay.2. Click “Pay Selected.”3. Complete the payment information and

click “Submit.”

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Payment History

To view your payment history, hover over “Payments” on the top navigation bar and select “View Payment History.” Here, you may:

• Use the filters to search transactions• Export transactions to Microsoft® Excel• Click “Details” to see the date a payment was

completed, scheduled, or canceled. You canalso see the amount paid, the confirmationnumber, and other payment details

• Print or download the Payment History pageas a PDF

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Export to Excel

This function exports a list of transactions to a Microsoft® Excel file, with columns for account number, invoice number, invoice date, and amount due. To use this feature, click “Export to Excel” from the “Bills” page.

Recurring Payments

To set up and manage recurring payments on your account, hover over “Payments” on the top navigation bar and select “View Recurring Payments.” Click “Add Recurring Payments” and follow the prompts.

Payment Accounts

To manage your accounts for making payments, hover over “Payments” on the top navigation bar and select “View Payment Accounts.” Click “Add Bank Account” or “Add Credit Card” and follow the prompts.

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Reports

Access “Reports” from the left-hand navigation. Your report options are:

• Order Status – Search and review your orders

• Invoice History Report – Search for past invoices either by invoice number or by date range

• Sales Order History – Search all orders placed (including those made by fax and phone)

• Usage Report – View product usage over time

• AWP/HCPCS – View Redbook AWP and HCPCS codes on products you’ve purchased

• Pedigree – View prescription drug pedigree

• Transaction History – View your transaction history

Checking Your Order Status

1. On the left-hand navigation, click “Reports.”2. Select the “Order Status” report.3. Click on the “Sales Order Number” of the order status you wish to check.4. The status can be found in the “Status” column.

• Submitted—the order has been received

• Confirmed—the order has been processed

• Shipped—the order has shipped and a tracking number is available

• Invoiced—the order has been invoiced to your account

Tracking Your Shipment

1. On the left-hand navigation, click “Track Shipments.”2. Click on the “Sales Order Number” of the order you wish to track.3. Click the “Tracking Number” to access the shipping carrier’s package tracking website.

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PARAGARD Direct™ Forms

With our e-sign forms, there is no need to fax forms since you can use an electronic signature. Simply complete the required fields and click “Submit.”

PARAGARD DirectTM Business Application (e-sign form) Use the PARAGARD Direct™ Business Application to establish your account.

Letter of Affiliation (e-sign form)

Use the Letter of Affiliation to establish the affiliation between the physician and entity to which PARAGARD will be shipped to.

PARAGARD Direct™ Order Form (e-sign or fax form)

Use the Order Form to submit an order.

Request to Modify Sales Terms (e-sign form)

Use the Request to Modify Sales Terms form to request adjustments to the sales terms on your account.

Account Update Request (e-sign form)

Use the Account Update Request form to make updates to your account information.

Declaration of Intention (e-sign form) Note: for Florida offices and organizations only. Use the Declaration of Intention to confirm your intention under the Florida Health Care Clinic Establishment (HCCE) Permit requirement.

Business Application Checklist

©2018 CooperSurgical, Inc. PAR-41326 April 2018

PARAGARD is a registered trademark and PARAGARD Direct™

is a trademark of CooperSurgical, Inc.

pg 1 of 4

WEB: PARAGARDDirect.com

PHONE: 1-877-PARAGARD (option 1, then option 5)

FAX: 1-469-365-8168


Please refer to the checklist below to ensure that you have provided all of the necessary documentation that is being requested. It is important to note that failure to provide complete and required documentation may result in a delay in account set-up.

Complete and return all 4 pages of the Business Application. Your application may become delayed if any fields are left blank or are altered by the applicant

Please initial page 3 and sign page 4 of the Business Application after reading the Terms and Conditions carefully

Provide a valid email address

Provide a DEA Number or Health Industry Number

Enclose a copy of a valid DEA registration

Enclose a copy of a valid Physician or Pharmacy State License and/or Permit

If located in Florida, provide a copy of the HCCE Permit or complete the Declaration of Intention, if required

Complete the Letter of Affiliation• If you are a legal entity and provide a physician license, the Letter of Affiliation must certify that the physician is affiliated with the entity• If you provide a physician license and the address on the license does not match the shipping address on page 2 of the Business

Application, the Letter of Affiliation must certify that the physician is affiliated with the shipping address

Provide copies of Articles/Certificate of Incorporation, Certificate of Formation, Partnership agreement, Certificate of Partnership or other evidence of entity formation and any d/b/a(s), as applicable

Provide a Tax ID #

If tax exempt, provide your tax exempt certificate

Email completed Business Application, Letter of Affiliation, and all supporting documents to [email protected] or fax it to 1-469-365-8168

Authorized to sign Business Application: Accountant, CEO, CFO, Contract Manager, Doctor, Inventory Manager, Midwife (as Owner Only), Nurse Practitioner (as Owner Only), Office Manager, Owner, Pharmacist (RPh), Pharmacist in Charge (PIC), Pharmacy Director, Purchaser, Purchasing Agent, Buyer, Corporate Secretary (Executive Assistant), Application Support Specialist, Physician Assistant (PAC), Supervisor

Those NOT authorized to sign include: Any Assistant (Other than Executive Assistant or Physician Assistant), Any Clerk, Registered Nurse (Unless they hold another authorized title), Nurse (Unless they hold another authorized title), Department Name (Must be a person’s title)

For assistance in completing the account set-up documentation,please call 1-877-PARAGARD (727-2427), option 1, then option 5.

Letter of Affiliation Checklist

PURPOSE: The purpose of the Letter of Affiliation (LOA) is to establish the affiliation between the physician and the ship-to entity. By completing this form, the physician will be responsible in all respects for the receipt and accountability of pharmaceutical products shipped to the entity listed on the form. The Letter of Affiliation is required with all new account set-ups.

Note: The Letter of Affiliation is also required when updating a physician’s license on an existing account.

REQUIRED FIELDS:

Physician License Information (Top Left) • Complete the name and license number as it appears on the Physician License of the physician that will be

signing the Letter of Affiliation

Entity Name and Address (Top Right)• Complete the entity name and address of the ship-to location. If there is more than one ship-to entity,

please include the additional ship-to entities at the bottom of the form. If more space is needed, you may list additional ship-to locations on a separate sheet of paper titled “Additional Ship-to Locations” and submit with the LOA

Physician Signature (Middle of Form)• The named physician on the license must sign the form, print name, and date

Supporting Documents• A copy of the valid license reflecting the license holder’s name

• If the ship-to entity is a clinic, the physician must submit a valid license or permit reflecting the name and address of the clinic

FPO

If you are opening a new account with PARAGARD Direct™: Please fax Letter of Affiliation along with supporting documents and Business Application to 1-469-365-8168. You may also email the documents to [email protected].

If you are updating a license on an existing account: Please fax Letter of Affiliation and copy of updated license to 1-800-299-8332. You may also email to [email protected].

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Direct™

Direct™

WEB: PARAGARDDirect.com

PHONE: 1-877-PARAGARD (option 1)

FAX: 1-800-299-8332


©2018 CooperSurgical, Inc. PAR-41325 April 2018

PARAGARD is a registered trademark, and PARAGARD Direct™

is a trademark of CooperSurgical, Inc.

Frequently Asked Questions

Account Set Up

Is it easy to set up a new PARAGARD Direct™ account?Yes! If you set up an account over the phone, one of our Specialists will complete all of the paperwork for you and send you the appropriate forms for your signature. You can also set up your account online. Please see page 11 for step-by-step instructions for creating your PARAGARD Direct™ account.

How long does it take to set up my account?If completed paperwork is received before 3:00 Pm CT, the account will be set up the same day.

Note: If all required fields on paperwork are not completed, account set up will be delayed. Please ensure paperwork is completed in full.

Orders

How long will it take to receive my order once it is shipped?Generally, orders are shipped on the same day. Our standard method of shipping is UPS Ground and you should receive your order within 3-5 business days. You may also request expedited shipping for an additional fee.

How do I check the status of my order?1. On the left-hand navigation, click “Reports.”2. Select the “Order Status” report.3. Click on the “Sales Order Number” of the order status you wish to check.4. The status can be found in the “Status” column.

• Submitted—the order has been received

• Confirmed—the order has been processed

• Shipped—the order has shipped and a tracking number is available

• Invoiced—the order has been invoiced to your account

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Why was my order placed on hold?Your order may be placed on hold due to an expired license, missing paperwork, a past-due balance, or a credit limit hold. If your order has been placed on hold, please call PARAGARD Direct™ at 1-877-PARAGARD, option 1.

How do I view tracking information for my order?Visit PARAGARDDirect.com and log in. On the left-hand navigation, click “Track Shipments.”

What should I do if my order is not in the system under tracked orders?While we hope this does not happen, we would ask that you please call PARAGARD Direct™ at 1-877-PARAGARD, option 1, to determine the status of your missing order.

What if my order was shipped, but I still haven’t received it?If your order was shipped within the last 5 days and you haven’t received it, please call PARAGARD Direct™ at 1-877-PARAGARD, option 1, and we will be happy to help you.

What if my credit card or e-check payment is denied? Please call us at 1-877-PARAGARD, option 1, and we will be happy to help you.

Getting Assistance

Who can I call if I have a question?Please call 1-877-PARAGARD, option 1.

What are the PARAGARD Direct™ business hours?Monday through Friday, 7:30 Am to 7:00 Pm CT.

PARAGARD Benefits VerificationSM

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WEB: PARAGARDbvsp.com PHONE: 1-888-275-8596

FAX: 1-855-215-5315


PARAGARD Benefits VerificationSM is designed to provide benefits information on each patient’s insurance coverage for PARAGARD. With this service, you can request a Benefits Verification Report and receive patient-specific coverage information, including reimbursement amounts when available.

To set up your online account:

1. Visit PARAGARDbvsp.com.2. Under “Create an Account,” click “Register.”3. Complete the Healthcare Provider Registration form and click “Submit.”

To request a Benefits Verification Report online:

1. Visit PARAGARDbvsp.com.2. Log in to your account.3. Click the “Refer New Patient” tab, complete the online Patient Referral Form, and

click “Submit.”4. Ask the patient to submit the Patient Authorization Form online using an electronic

signature (see instructions on pages 34-35).

To request a Benefits Verification Report by fax:

1. Visit PARAGARDbvsp.com.2. Click “Download the Patient Authorization and Referral Forms” at the bottom of

the screen.3. Print the forms.4. Have your patient complete the Patient Authorization form.5. Complete the Patient Referral form.6. Fax both forms to 1-855-215-5315.

Quick Start Guide

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Request a Benefits Verification Report by phone:

1. Call 1-888-275-8596 to request the Patient Authorization and Patient Referral forms.2. Have your patient complete the Patient Authorization form.3. Complete the Patient Referral form.4. Fax both forms to 1-855-215-5315.

Please note that only Benefits Verification Reports requested online are shown on the portal website. To check the status of reports requested via fax or over the phone, please call 1-888-275-8596.

Looking for more quick tips for using PARAGARD Benefits VerificationSM? Please go to page 36 for PARAGARD Benefits VerificationSM Frequently Asked Questions.

Getting Started

Setting up your online account

For the easiest, most convenient access to PARAGARD Benefits VerificationSM, create an account online. Our online portal allows you to refer an unlimited number of patients online, access Patient Authorization forms, and view the status of Benefits Verification Reports for all of your current patients. By creating an online account, you can also generate PARAGARD Specialty PharmacySM and PARAGARD Patient Direct™ requests, all with the click of a button. If you choose to request Benefits Verification by fax or phone only, there is no need to register.

Set up your account online:

1. Visit PARAGARDbvsp.com.2. Under “Create an account,” click “Register.”3. Complete the Healthcare Provider Registration form and click “Submit.”

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To request a Benefits Verification Report by fax:1. Visit PARAGARDbvsp.com.2. Click “Download the Patient Authorization and Referral Forms”

at the bottom of the screen.3. Print the forms.4. Have your patient complete the Patient Authorization form.5. Complete the Patient Referral form.6. Fax both forms to 1-855-215-5315.

Your patient’s Benefits Verification Report will be delivered within 1-2 business days.

To request a Benefits Verification Report by phone:1. Call 1-888-275-8596 to request the Patient Authorization and Patient Referral forms.2. Have your patient complete the Patient Authorization form.3. Complete the Patient Referral form.4. Fax both forms to 1-855-215-5315.

Your patient’s Benefits Verification Report will be delivered within 1-2 business days.

Requesting a PARAGARD Benefits VerificationSM Report

To request a Benefits Verification Report online:1. Visit PARAGARDbvsp.com.2. Log in to your account.3. Click the “Refer New Patient” tab, complete the online Patient Referral Form, and click “Submit.”4. Ask the patient to submit the Patient Authorization Form online using an electronic signature (see

instructions on pages 34-35).

Your patient’s Benefits Verification Report will be available online within 1-2 business days.

Benefit VerificationSM

Benefits VerificationSM

Specialty PharmacySM

Specialty PharmacySMPatient Authorization Form

PARAGARDIn accordance with the Health Insurance Portability and Accountability Act of 1996 and related federal regulations and rules (“HIPAA”), this Authorization authorizes my healthcare provider, health plan, and my pharmacy to disclose my health and personal information to CooperSurgical, Inc. and its agent, Biologics, Inc. (and its affiliates, and their respective representatives, and agents [collectively, “Biologics”]) in furtherance of the below-stated authorized purposes. The “PARAGARD” program is operated by Biologics on behalf of CooperSurgical, Inc.

Authorized PurposesI understand that the PARAGARD Program and Biologics will receive my health and personal information for the following purposes: (1) to conduct benefit verification determining insurance reimbursement and coverage of PARAGARD; (2) if my physician selects that the PARAGARD unit is shipped by a specialty pharmacy, to contact me to discuss any relevant co-pay, to bill the insurance company, to bill the applicable co-pay and to ship the unit to my healthcare provider; (3) to contact me by telephone in furtherance of conducting benefits verifications investigations; and (4) if I select the PARAGARD Patient DirectTM self-pay option, to invoice me and to otherwise contact me to collect payment for the PARAGARD unit.

By signing the following form, I understand:

1. Once my healthcare provider gives Biologics and the PARAGARD Program information about me based on this Authorization, my medical and health information may be subject to redisclosure and is no longer protected by federal privacy regulations.

I further understand and agree that Biologics and the PARAGARD Program may retain my medical and health information as disclosed under this Authorization after this authorization expires.

I also understand that in the event of an audit, and for purposes of such an audit, some information may also be disclosed to CooperSurgical, Inc., the manufacturer of PARAGARD, or its affiliates after this Authorizationhas expired, so long as the audit is for a period of time when this Authorization was in effect.

2. I may refuse to sign this Authorization form and that, unless allowed by law, my refusal to sign will not affect my ability to obtain treatment from my healthcare provider; or to seek payment; or my eligibility for insurance benefits.

3. I may revoke my authorization at any time by providing a written notice of same to my healthcare provider that refers to (or with a copy of) this Authorization form, or to Biologics/the PARAGARD Program at 11800 Weston Parkway, Cary, NC 27513. However, I understand that if I revoke this authorization, it will not affect prior disclosures made by my healthcare provider to Biologics and any use of such information by Biologics in reliance of this authorization. I understand that I have the right to receive a copy of this Authorization.

4. This Authorization shall expire one year after I have signed it, or upon revocation, whichever is earlier.

Signature of Patient or Personal Representative Date

Name of Patient or Personal Representative

(If Applicable) Description of Personal Representative’s Authority to Sign for Patient

©2018 CooperSurgical, Inc. PAR-41328 January 2018

PARAGARD is a registered trademark, PARAGARD Patient Direct™ is a trademark, and PARAGARD Benefits VerificationSM and PARAGARD Specialty PharmacySM are service marks of CooperSurgical, Inc.

WEB: PARAGARDbvsp.comPHONE: 1-888-275-8596FAX: 1-855-215-5315

Note: Access to Benefits Verification Reports online is only available for patient referrals submitted online.!

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Accessing the PARAGARD Benefits VerificationSM Report

To view or check the status of a Benefits Verification Report referred online:1. Visit PARAGARDbvsp.com.2. Log in to your account.3. On the “Current Patients” screen, you can view the status of the Benefits Verification Report in the

“Status” column, or click the icon to view a PDF of the report.

To check the status of or view a Benefits Verification Report referred by fax or phone:

Your patient’s Benefits Verification Report will be faxed to your office 1-2 days after we receive the paperwork. To check the status of a Benefits Verification Report that was referred by fax or phone, please call 1-888-275-8596.

Patient Referral Form

The Patient Referral form provides required patient information for PARAGARD Benefits VerificationSM service. To submit a benefits verification request, this form must be completed.

The fastest way to complete and submit this form is online. Once you log in, select “Refer New Patient.” Fill in the required fields and click “Submit.” You may also print this form from our website and fax it to 1-855-215-5315.

Patient Authorization Form

The Patient Authorization Form is required in order to provide patient consent for the PARAGARD Benefits VerificationSM service. Signed forms can be submitted by fax or online with an electronic signature(see electronic signature instructions on pages 34-35).

PARAGARD Benefits VerificationSM Forms




Specialty PharmacySMPatient Referral Form



How do you intend to obtain PARAGARD?

N/A, PARAGARD Benefits VerificationSM Only PARAGARD DirectTM PARAGARD Specialty Pharmacy SM PARAGARD Patient DirectTM

(Buy & Bill) (Patient Self-Pay)

PARAGARD Specialty PharmacySM NOTIFICATION: By submitting this prescription request form and checking the PARAGARD Specialty PharmacySM box above, prescriber and patient are aware that Biologics, Inc. will ship upon verification of benefits and collection of applicable co-pay.

Would you like a benefits verification report sent to your office before sending to the pharmacy? Yes No

PARAGARD® Prescriber must call 1-888-275-8596 to cancel shipment. PARAGARD® T 380A Qty: 1

To be inserted one time by prescriber. Route intrauterine. Requested date of delivery: Prescriber gives Biologics, Inc. express permission to use his/her NPI number included herein for the purpose of identifying the referring prescriber to the authorized pharmacy benefits manager and/or payer. Biologics, Inc. accepts no liability regarding any decisions concerning claims coverage or payment, which remain the responsibility of the health plan administrators and insurers. Biologics, Inc. makes no assurance that any prescribed drug or treatment will be covered under any patient’s insurance plan or that any pharmacy will provide the prescribed drug or treatment.

Prescriber Signature: Date:

For ARNP, NP, and PA, collaborative physician agreement is with: Date:

FOR PATIENT

First Name: Middle Initial: Last Name:

Date of Birth:

Street Address: City: State: ZIP:

Phone: Alternate Phone: Scheduled Placement Date:

Insurance Information N/A (Patient Self-Pay)

(Please attach copies of the front and back of medical and prescription drug insurance cards with request.)

Primary Insurer: Phone Number:

Subscriber Name: Subscriber ID:

RxBIN: RxPCN: RxGrp:

Service Requested PARAGARD Benefits VerificationSM PARAGARD Specialty PharmacySM PARAGARD Patient DirectTM

(Patient Self-Pay)(check only those that apply)

FOR HEALTHCARE PROVIDER

Prescriber Name: Specialty:

Group or Hospital: Contact Name:


Phone: Fax:

NPI: Tax ID:

J code: J7300

Group Number: Subscriber DOB: Employer Name:

ICD-10 Coding

Z30.430 Encounter for insertion of intrauterine contraceptive device Other Please specify:

If your patient is a minor and is signing the authorization on the following page on her own behalf, please affirm that:

This patient has the capacity to consent to treatment with PARAGARD under the law of the state in which I practice (and the consent of a parent or guardian is not required), or

This patient’s parent or guardian has consented to the patient’s treatment with PARAGARD

(Does not apply to the following: Alaska, Arkansas, California, Colorado, District of Columbia, Georgia, Hawaii, Idaho, Iowa, Kentucky, Maryland, Minnesota, North Carolina, New Mexico, Oregon, Tennessee, or Virginia)







Authorized PurposesI understand that the PARAGARD Program and Biologics will receive my health and personal information, which may include my name, address, patient insurance identification number, date of birth and other information necessary to obtain health insurance benefit verification for the following purposes: (1) to conduct benefit verification determining insurance reimbursement and coverage of PARAGARD; (2) if my physician selects that the PARAGARD unit is shipped by a specialty pharmacy, to contact me to discuss any relevant co-pay, to bill the insurance company, to bill the applicable co-pay and to ship the unit to my healthcare provider; (3) to contact me by telephone in furtherance of conducting benefits verifications investigations; and (4) if I select the PARAGARD Patient DirectTM self-pay option, to invoice me and to otherwise contact me to collect payment for the PARAGARD unit.




I also understand that in the event of an audit, and for purposes of such an audit, some information may also be disclosed to CooperSurgical, Inc., the manufacturer of PARAGARD, or its affiliates after this Authorization

has expired, so long as the audit is for a period of time when this Authorization was in effect.















Authorized PurposesI understand that the PARAGARD Program and Biologics will receive my health and personal information, which may include my name, address, patient insurance identification number, date of birth and other information necessary to obtain health insurance benefit verification for the following purposes: (1) to conduct benefit verification determining insurance reimbursement and coverage of PARAGARD; (2) if my physician selects that the PARAGARD unit is shipped by a specialty pharmacy, to contact me to discuss any relevant co-pay, to bill the insurance company, to bill the applicable co-pay and to ship the unit to my healthcare provider; (3) to contact me by telephone in furtherance of conducting benefits verifications investigations; and (4) if I select the PARAGARD Patient DirectTM self-pay option, to invoice me and to otherwise contact me to collect payment for the PARAGARD unit.














3534

Patient Authorization Electronic Signature Instructions

Patients can review and provide their signature electronically for the Patient Authorization Form by utilizing our DocuSign tool online. We have detailed the step-by-step process below.

1. Ask the patient to visit www.PARAGARDbvsp.com.

2. At the bottom of the page on the pink bar, the patient/legal guardian should click where it says“click here” to start the electronic signature process.

3. The patient/legal guardian should then enter theirname and email in the fields. Once both fields havebeen completed, click in thelower-right corner.

Please note: If a legal guardian’s signature will be needed, please enter that name and email address rather than the patient’s. The completed form will be sent to the entered email address.

4. Read the “Electronic Record and Signature Disclosure” and indicate consent by checkingthe “I agree” box.

5. Click to move forward.

6. The patient/legal guardian should then read the Patient Authorization Form in full.

7. The patient/legal guardian will then

be prompted to sign on the designated

lines marked by the button.

Clicking will display the

“Adopt Your Signature” window.

Ensure the patient/legal guardian name and initials are correct for the party signing the form, and click

.

8. If a legal guardian is signing on behalf of the patient, they should indicate their relationshipto the patient in the "Description of Personal Representative" field. If the patient is signingfor herself, she should enter "N/A" in that field.

9. Once all fields have been completed, click at the top or bottom of the screen. The completed document can be downloaded by selecting . A copy will also be sent to the patient’s/legal guardian’s email address provided.

10. To finish the request, the healthcare provider will need to submit a Patient Referral Formfor the patient.

36


Requesting a Benefits Verification Report

How do I refer a patient for benefits verification?A patient can be referred for PARAGARD Benefits VerificationSM online, by fax, or by phone. Please see page 30 for step-by-step instructions for referring a new patient.

Accessing a Benefits Verification Report

How long does it take to receive a Benefits Verification Report?Benefits Verification Reports are generally delivered within 1-2 business days. During times with a high volume of requests, the process may take more time to complete.

Why isn’t the report I requested showing in the online portal?It may be that you submitted your request via phone or fax. Only online submissions appear in the online portal. If you submitted your request online and you do not see it in the online portal, please give us a call at 1-888-275-8596.

Getting Assistance

Who can I call if I have a question about my benefits verification request?Please call us at 1-888-275-8596.

What are the PARAGARD Benefits VerificationSM business hours?Monday through Friday, 9:00 Am to 6:00 Pm ET.

PARAGARD Specialty PharmacySM

PA

RA

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ecialty Pharm

acyS

M

39

With PARAGARD Specialty PharmacySM, your patient’s prescription for PARAGARD is fulfilled through our Specialty Pharmacy and shipped directly to your office. The Specialty Pharmacy will also process the claim with your patient’s health insurer and collect any applicable co-pay for the unit.

WEB: PARAGARDbvsp.com

PHONE: 1-888-275-8596

FAX: 1-855-215-5315


To request PARAGARD Specialty PharmacySM online*:

1. Visit PARAGARDbvsp.com.2. Log in to your account (see page 29 for how to set up your online account).3. On the “Current Patients” tab, find the patient’s name and in the “Payment Method”

column select “Specialty Pharmacy.”4. Click “Submit.”5. Fax the patient’s prescription for PARAGARD to 1-888-215-5315.

* You may only request Specialty Pharmacy through our online portal if the patient has been previously referredfor PARAGARD Benefits VerificationSM through our online portal.

To request PARAGARD Specialty PharmacySM by fax:

1. Visit PARAGARDbvsp.com.2. Click “Download the Patient Authorization and Referral Forms” at the bottom of

the screen.3. Print the forms.4. Have your patient complete the Patient Authorization form.5. Complete the Patient Referral form. On the bottom of the form, be sure to check the box

next to “PARAGARD T 380A Qty: 1.”6. Fax both forms to 1-855-215-5315.

Quick Start Guide

4140

Patients can submit the Patient Authorization Form online using an electronic signature (see instructions on pages 34-35).

To request PARAGARD Specialty PharmacySM by phone:

1. Call 1-888-275-8596 to request the Patient Authorization and Patient Referral forms.2. Print the forms.3. Have your patient complete the Patient Authorization form.4. Complete the Patient Referral form. On the bottom of the form, be sure to check the

box next to “PARAGARD T 380A Qty: 1.”5. Fax both forms to 1-855-215-5315.

Getting Started

Requesting PARAGARD Specialty PharmacySM Services

To request PARAGARD Specialty PharmacySM online*:1. Visit PARAGARDbvsp.com.2. Log in to your account (see page 29 for how to set up your online account).3. On the “Current Patients” tab, find the patient’s name and in the “Payment Method”

column select “Specialty Pharmacy.”4. Click “Submit.”5. Fax the patient’s prescription for PARAGARD to 1-888-215-5315.

* You may only request Specialty Pharmacy through our online portal if the patient has been previouslyreferred for PARAGARD Benefits VerificationSM through our online portal.

4342

The PARAGARD Specialty PharmacySM Service

1. Once we receive your completed forms, we will first conduct a PARAGARD Benefits VerificationSM.2. If it is determined that PARAGARD is covered, then the prescription will be sent to our

Specialty Pharmacy for fulfillment.3. Our Specialty Pharmacy will process the claim with your patient’s health insurer and

collect any applicable co-pay for the unit.4. Our Specialty Pharmacy will fill the prescription and contact your office to confirm the

shipping date and verify your address.5. When the unit has shipped, you will receive a shipping confirmation via fax.

Requesting PARAGARD Specialty PharmacySM Services continued

To request PARAGARD Specialty PharmacySM services by fax:1. Visit PARAGARDbvsp.com2. Click “Download the Patient Authorization and Referral Forms” at the bottom of the screen.3. Print the forms.4. Have your patient complete the Patient Authorization form.5. Complete the Patient Referral form. On the bottom of the form,

be sure to check the box next to “PARAGARD T 380A Qty: 1.”6. Fax both forms to 1-855-215-5315.

To request PARAGARD Specialty PharmacySM services over the phone:1. Call 1-888-275-8596 to request the Patient Authorization and Patient Referral forms.2. Print the forms.3. Have your patient complete the Patient Authorization form.4. Complete the Patient Referral form. On the bottom of the form, be sure to check the box next to

“PARAGARD T 380A Qty: 1.”5. Fax both forms to 1-855-215-5315.

Note: Patients can submit the Patient Authorization Form online using an electronic signature (see instructions on pages 34-35).

4544

PARAGARD Specialty PharmacySM Forms


The Patient Authorization Form is required in order to provide patient consent for the PARAGARD Specialty PharmacySM service. Signed forms can be submitted by fax or online with an electronic signature (see electronic signature instructions on pages 34-35).











2. I may refuse to sign this Authorization form and that, unless allowed by law, my refusal to sign will not affect myability to obtain treatment from my healthcare provider; or to seek payment; or my eligibility for insurance benefits.

3. I may revoke my authorization at any time by providing a written notice of same to my healthcare provider thatrefers to (or with a copy of) this Authorization form, or to Biologics/the PARAGARD Program at 11800 Weston Parkway, Cary, NC 27513. However, I understand that if I revoke this authorization, it will not affectprior disclosures made by my healthcare provider to Biologics and any use of such information by Biologics in reliance of this authorization. I understand that I have the right to receive a copy of this Authorization.




























The Patient Referral form provides required patient information for the PARAGARD Specialty PharmacySM service. To order PARAGARD through our Specialty Pharmacy, this form must be completed. On the bottom of the form, be sure to check the box next to “PARAGARD T 380A Qty: 1.” Fax it to 1-855-215-5315.
















FOR PATIENT


Date of Birth:














Phone: Fax:

NPI: Tax ID:

J code: J7300


ICD-10 Coding







46


Using Specialty Pharmacy

Can I refer a patient for Specialty Pharmacy services online?You may only request Specialty Pharmacy via our online portal if the patient has been previously referred for PARAGARD Benefits VerificationSM through our online portal. See page 30 for how to refer patients to PARAGARD Benefits VerificationSM online.

How do I refer a patient for Specialty Pharmacy services by fax or over the phone?Please refer to page 38 in this section of the guide.

How long does it take to receive PARAGARD through Specialty Pharmacy?Once all paperwork has been processed and the placement date has been confirmed, you can expect to receive PARAGARD approximately 1 week prior to the placement date. One of our Specialists will reach out to you to confirm the shipping date and verify your address. You will also receive shipping confirmation via fax.

Special Circumstances

What if we need to bill for other services done on the same day as PARAGARD placement?We only collect co-pays and submit claims for PARAGARD. You will need to bill separately for any other services completed on the day of insertion, including the insertion procedure.

Getting Assistance

Who can I call if I have a question about PARAGARD Specialty PharmacySM?Please call 1-888-275-8596.

What are the PARAGARD Specialty PharmacySM business hours?Monday through Friday, 9:00 Am to 6:00 Pm ET.

PARAGARD Patient Direct™

PA

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Patient D

irect ™

49

PARAGARD Patient Direct™ is a solution for patients who choose to self-pay for PARAGARD. PARAGARD Patient Direct™ allows patients who have a prescription for PARAGARD to order the unit and have it sent to your office for placement.

WEB: PARAGARDbvsp.com

PHONE: 1-888-275-8596

FAX: 1-855-215-5315


Quick Start Guide

To request PARAGARD Patient Direct™ online*:

1. Visit PARAGARDbvsp.com.2. Log in to your account (see page 29 for how to set up your online account).3. On the “Current Patients” tab, find the patient’s name and in the “Payment Method” column

select “Self-Pay.”4. Click “Submit.”5. Fax the patient’s prescription for PARAGARD to 1-888-215-5315.

* You may only generate a patient self-pay request through our online portal if the patient has been previously referredfor PARAGARD Benefits VerificationSM through our online portal.

To request PARAGARD Patient Direct™ by fax:

1. Visit PARAGARDbvsp.com.2. Click “Download the Patient Authorization and Referral Forms” at the bottom of the screen.3. Print the forms.4. Have your patient complete the Patient Authorization form.5. Complete the Patient Referral form. On the bottom of the form, be sure to check the box

next to “PARAGARD T 380A Qty: 1.”6. Fax both forms to 1-855-215-5315.

5150

Patients can submit the Patient Authorization Form online using an electronic signature (see instructions on pages 34-35).

To request PARAGARD Patient Direct™ by phone:

Either you or your patient can initiate a purchase through PARAGARD Patient Direct™ by phone.

1. Call 1-888-275-8596 and let us know your patient would like to self-pay forPARAGARD.

2. We will send you the Patient Authorization and Patient Referral forms.3. Print the forms and have your patient complete the Patient Authorization form.4. Complete the Patient Referral form. On the bottom of the form, be sure to check the

box next to “PARAGARD T 380A Qty: 1.”5. Fax both forms to 1-855-215-5315.

Getting Started

Requesting PARAGARD Patient Direct™ Services

To request PARAGARD Patient Direct™ online*:1. Visit PARAGARDbvsp.com.2. Log in to your account (see page 29 for how to set up your online account).3. On the “Current Patients” tab, find the patient’s name and in the “Payment Method” column select

“Self-Pay.”4. Click “Submit.”5. Fax the patient’s prescription for PARAGARD to 1-888-215-5315.

* You may only generate a patient self-pay request through our online portal if the patient has been previously referred forPARAGARD Benefits VerificationSM through our online portal.

To request PARAGARD Patient Direct™ by fax:1. Visit PARAGARDbvsp.com.2. Click “Download the Patient Authorization and Referral Forms” at the bottom of the screen.3. Print the forms.4. Have your patient complete the Patient Authorization form.5. Complete the Patient Referral form. On the bottom of the form, be sure to check the box next to

“PARAGARD T 380A Qty: 1.”6. Fax both forms to 1-855-215-5315.

5352

To request PARAGARD Patient Direct™ by phone:Either you or your patient can initiate a purchase through PARAGARD Patient Direct™ by phone.1. Call 1-888-275-8596 and let us know that your patient would like to self-pay for PARAGARD.2. We will send you the Patient Authorization and Patient Referral forms.3. Print the forms and have your patient complete the Patient Authorization form.4. Complete the Patient Referral form. On the bottom of the form, be sure to check the box next

to “PARAGARD T 380A Qty: 1.”5. Fax both forms to 1-855-215-5315.

Note: Patients can submit the Patient Authorization Form online using an electronic signature (see instructions on pages 34-35).

The PARAGARD Patient Direct™ Service

1. Once we receive your completed forms, we will first conduct a Benefits Verification to see if thepatient has insurance coverage for PARAGARD.

2. We will contact the patient by phone to inform her of the price. If the patient confirms she agreesto the price, the prescription will be sent to our Specialty Pharmacy for fulfillment.

3. One of our Specialists will coordinate payment with the patient.4. Our Specialty Pharmacy will fill the prescription and contact your office to confirm the shipping

date and verify your address.5. When the unit has shipped, you will receive a shipping confirmation via fax.

5554

PARAGARD Patient Direct™ Forms


The Patient Authorization Form is required in order to provide patient consent for the PARAGARD Patient DirectTM service. Signed forms can be submitted by fax or online with an electronic signature (see electronic signature instructions on pages 34-35).


The Patient Referral form provides required patient information for the PARAGARD Patient DirectTM service. To order through PARAGARD Patient Direct™, this form must be completed. On the bottom of the form, be sure to check the box next to “PARAGARD T 380A Qty: 1.” Fax it to 1-855-215-5315.
















FOR PATIENT


Date of Birth:














Phone: Fax:

NPI: Tax ID:

J code: J7300


ICD-10 Coding






WEB: PARAGARDbvsp.comPHONE: 1-888-275-8596FAX: 1-855-215-5315Benefit VerificationSM










2. I may refuse to sign this Authorization form and that, unless allowed by law, my refusal to sign will not affect myability to obtain treatment from my healthcare provider; or to seek payment; or my eligibility for insurance benefits.

3. I may revoke my authorization at any time by providing a written notice of same to my healthcare provider thatrefers to (or with a copy of) this Authorization form, or to Biologics/the PARAGARD Program at 11800 Weston Parkway, Cary, NC 27513. However, I understand that if I revoke this authorization, it will not affectprior disclosures made by my healthcare provider to Biologics and any use of such information by Biologics in reliance of this authorization. I understand that I have the right to receive a copy of this Authorization.



























56


Using PARAGARD Patient Direct™

Can I refer a patient for PARAGARD Patient Direct™ online?You may only request patient self-pay via our online portal if the patient has been previously referred for PARAGARD Benefits VerificationSM through our online portal. See page 30 for how to refer patients to PARAGARD Benefits VerificationSM online.

How do I refer a patient for PARAGARD Patient Direct™ by fax or over the phone? Please refer to page 50 in this section of the guide.

How long does it take to receive PARAGARD through PARAGARD Patient Direct™?Once all paperwork has been processed and the placement date has been confirmed, you can expect to receive PARAGARD approximately 1 week prior to the placement date. One of our Specialists will reach out to you to confirm the shipping date and verify your address. You will also receive a shipping confirmation via fax.

Getting Assistance

Who can I call if I have a question about PARAGARD Patient Direct™?Please call 1-888-275-8596.

What are the PARAGARD Patient Direct™ business hours?Monday through Friday, 9:00 Am to 6:00 Pm ET.

Making access easier for your patients who choose PARAGARD.

PARAGARDAccessCenter.com 1-877-PARAGARD

PARAGARD is a registered trademark, PARAGARD Access Center™, PARAGARD Direct™ and PARAGARD Patient Direct™ are trademarks, and PARAGARD Benefits VerificationSM and PARAGARD Specialty PharmacySM are service marks of CooperSurgical, Inc.

© 2020 CooperSurgical, Inc. US-PAR-1800004 February 2020