Fill out the Prescription Request Form
Access the form here

TIP! You can personalize prescription Request Forms to keep on hand. Just download the form to your computer, type in your practice information, and save for quick-printing as needed.

TIP! To save time, have your patient fill in their name, address, and insurance
information. (Make a copy of the insurance card for their file.)

Fax the form to our specialized pharmacy partner (CVS/Caremark) at 1-800-410-1180
Get a fax cover sheet here

TIP! Be sure to fully complete the Prescription Request Form! The service will not
begin its Benefits Investigation Process until all information is completed.

Receive a reply fax confirming that CVS/Caremark has received your fully completed
request form and can begin the Benefits Investigation Process

• CVS/Caremark will telephone you if any information is missing from the request
  form
• If you do not receive a fax confirmation within 72 hours, visit
  ArestinRxAccess.com to view the same status of the prescription or call
  ARESTIN^® Rx Access Customer Service at 1-866-9GUMSRX (948-6779)

Tell patient to expect a call within 3 business days

• If approved, the call comes from CVS.com to collect their co-pay via credit or
  debit card
• If denied, the call comes from your office to discuss their treatment plan using
  your office-stocked ARESTIN^®

Get patient instruction brochure here

Schedule patient's next treatment visit—typically 10 to 14 days later

Download a patient brochure about SRP + ARESTIN^® treatment

Within 3 business days, CVS/Caremark checks patient's prescription coverage for
ARESTIN^® and coordinates benefits with health insurer (if approved)

Visit ArestinRxAccess.com to view the status of the prescription or call
ARESTIN^® Rx Access Customer Service at 1-866-9GUMSRX (948-6779) if
you have questions

APPROVED >> PHARMACY CONTACTS YOUR OFFICE & YOUR PATIENT

• CVS/Caremark will fax notice of approval to your office within 3 business days
  of receiving your Prescription Request Form
• CVS/Caremark will also telephone your approved patient within 3 business days
  to collect co-pay
  –  

  When patient co-pay is received, your office receives a faxed confirmation of
  payment and intended delivery date.
• CVS/Caremark makes 3 attempts to contact approved patients by phone to
  collect co-pay
  –  

  If patient's co-pay cannot be collected, CVS/Caremark will telephone your
  office to inform you.

  –  

  If you have questions, call ARESTIN^® Rx Access Customer Service at
  1-866-9GUMSRX (948-6779)

  –  

  View your Prescription Request Form submission status at
  ArestinRxAccess.com

TIP! When you receive notification that a patient's coverage has been approved,
it may help to call and remind the patient that his/her co-pay must be paid
promptly and to return for their scheduled treatment visit.

DENIED >> USE ARESTIN^® FROM OFFICE STOCK

• CVS/Caremark will fax notice of coverage denial to your office within 3 business
  days of receiving your Prescription Request Form

Visit ArestinRxAccess.com to view the status of the prescription or call
ARESTIN^® Rx Access Customer Service at 1-866-9GUMSRX (948-6779) if
you have questions

Because CVS/Caremark does not contact patients if their prescription benefits
do not cover ARESTIN^®, your office should contact the patient right away to:

Place online order for ARESTIN^® if you don't have enough product on hand.

APPROVED >> PHARMACY SHIPS ARESTIN^®

• Product is shipped directly to your office by express mail to arrive by date you
  indicated on Prescription Request

Visit ArestinRxAccess.com to view the status of the prescription or call
ARESTIN^® Rx Access Customer Service at 1-866-9GUMSRX (948-6779) if
you have questions

DENIED >> USE ARESTIN^® FROM OFFICE STOCK

Place online order for ARESTIN^® if you don't have enough product on hand.