All Major Commercial and Medicaid Plans Accepted
*some 3rd party HMOs excluded
*UHC insurance is temporarily not accepted.
IUD REQUEST FORM
Please Complete All Sections
*MyIUDSupply will contact the patient for order confirmation
IMPORTANT: Prescriber gives MyIUDSupply.com 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. MyIUDSupply.com accepts no liability regarding any decisions concerning claims, coverage or payment, which are made in the sole discretion of the health plan administrators and insurers. MyIUDSupply.com makes no assurance that any prescribed drug will be covered or reimbursed at any specific level under any patient’s insurance plan, or that any specific pharmacy will provide the prescribed drug.