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WHC Support Center Forms

Ordering and Reimbursement for Kyleena, Mirena, and Skyla

Reimbursement

Information

Sample IUD CMS 1500

IUD Coverage Program Flashcard

Support Programs Resource Folder

Quick Reference Guide for Copay Savings Program

Forms

Benefits Investigation Office Worksheet

Benefit Investigation Patient Guide

IUD Coverage Program Form

Rebate Reimbursement Request Form

Sample Letters

Intrauterine System (IUS) WAC Price Information – HCP/Office Manager

Kyleena Letter of Appeals
Kyleena Letter of Medical Necessity
Mirena Letter of Medical Necessity

Product Ordering

Information

Volume Discount Program

Forms
Bayer WHC Support Wholesale Order

No Call Authorization

ASD Account Setup Initiation

Specialty Pharmacy

Information

SP Patient Reminder Form

Texas Commercial Health Plan - SP Alignment

Texas Medicaid and Healthy Texas Women - SP Alignment

Forms

SP Prescription

SP Prescription – LA Medicaid

SP Prescription – TX Medicaid

Abandoned Unit FAQ and Form

BAYER, the Bayer Cross, Kyleena, Mirena, and Skyla are registered trademarks of Bayer.

Copyright ©2020 Bayer. All rights reserved.

You are encouraged to report side effects or quality complaints of products to the FDA by visiting www.fda.gov/medwatch, or call 1-800-FDA-1088. For Bayer products, you can report these directly to Bayer by clicking here.