UniCare Health Plan of Kansas, Inc. State Sponsored Business

Mirena® (levonorgestrel-releasing intrauterine system) Enrollment Form Fax completed form to: CuraScript Fax number: 1-866-545-0062 | Provider Services phone number: 1-888-662-0944 Part I Patient Information Patient’s last name First name Middle initial

Address

City State ZIP code

Day phone number Night phone number Date of birth ( ) - ( ) - / / Parent/Guardian Allergies Sex M F Primary insurance Secondary insurance

Cardholder name (if not patient) Cardholder name (if not patient)

Member ID and Group number BIN# Member ID and Group number BIN#

Insurance phone number (+area code) Insurance phone number (+area code) ( ) - ( ) - Employer Employer

Part II Physician Information (please supply copy of patient’s insurance card) Prescriber’s name Hospital/Clinic Office contact name

Address

City State ZIP code

Phone number (+area code) Fax number (+area code) ( ) - ( ) - DEA number NPI UPIN

Part III Medical Criteria (double click on the fields below to fill in this form electronically) Medical Criteria: Diagnosis: ______ICD-9: ______Yes No: Patient has had at least one child & is requiring contraception for up to 5 years. Yes No: Has the patient had a pregnancy test within the past 2 weeks? If yes, what were the results? Positive Negative Yes No: Is the patient currently using pharmaceutical contraception or used pharmaceutical contraception in the past? If yes, drug(s) used and dates of therapy: Drug: Date: / / Duration: Drug: Date: / / Duration: Drug: Date: / / Duration: Dose the patient have a history of any of the following? Ectopic pregnancy Pelvic inflammatory disease Serious infection within 3 months of pregnancy Immunosuppressive disease Uterine cancer Liver disease / cancer Breast cancer Prescription: One intrauterine device placed in the uterine cavity within 7 day s of onset of menstruation or immediately after first- trimester abortion Prescriber’s signature Date / / CuraScript is able to fill your request as written. Please provide the following information to expedite your order: CuraScript to dispense (check box) Ship medication to: Physician Office/Clinic (Only)

UniCare Health Plan of Kansas, Inc. ® Registered mark of WellPoint, Inc. Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members. 0109 KSW2396 11/11 State Sponsored Business, UniCare Health Plan of Kansas, Inc. Mirena® (levonorgestrel-releasing intrauterine system) Enrollment Form Page 2 of 2

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