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Patient Information

Last Name

First Name

Home Address

Shipping Address (If different from above)

Home Address 2

Work Phone

Cell / Other Phone

Home Phone

Prescriber Information

Language Pref: English Spanish Other

Drug Allergies NKDA

DOB Last Four of SS# Gender: M F Physician’s Name

Office Contact Name

Today’s Date

Name of Practice / Hospital

Practice / Hospital Address

City State Zip

City State Zip Phone

DEA #

NPI #

Fax

Clinical Information (Section must be completed to process prescription)

Prior Treatment History

Abbvie Skilled Nurse Training:

In patient’s home or clinic In physician’s office

In patient’s home In physician’s office

Abbvie Skilled Nurse Training and Injection:

Nurse Training:

Does patient have Multiple Sclerosis or any demyelinating disease? Yes No

Does patient have CHF? Yes No

Height cm in kg lbsWeight

TB / PPD Test: Negative Positive

Years with DiseaseDate of Diagnosis

Medical Justification for Prescribing Biologic Therapy (or attach relevant history):

Contraindications (List)

Topicals (List) Duration

Duration PUVA Duration UVB

Side Effects, Lab Abnormalities, Toxicity Issues (List)

Other (List)Duration Sulfasalazine

Duration MethotrexateDuration Oral Retinoids (Soriatane, Accutane) Duration Cyclosporine

No Response to Previous Treatment (List)

Primary Diagnosis:

Body Surface Area Affected %

Date of Diagnosis

L40.59 Other psoriatic arthropathy

L40.1 Generalized pustular psoriasis

L40.2 Acrodermatitis continua

L40.3 Pustulosis palmaris et plantaris

L40.4 Guttate psoriasis

L40.8 Other psoriasis

L40.54 Psoriatic juvenile arthropathy

L40.0 Psoriasis vulgaris

L73.2 Hidradenitis suppurativa

Description

Other Diagnosis: ICD-10 Code

Non-Infectious Intermediate Uveitis

Posterior Uveitis

Panuveteitis

Insurance Information (Must fax a copy of patient’s insurance card including both sides)

Dermatology Biologics Therapy Prescription Form

Fax:

Phone:

Prior Authorization Reference number

Plaque Psoriasis Starter Packs

Maintenance Dose

Medication Dose / Strength Directions RefillsPrescription Information

Ship to: Patient Office Other Needs by Date

Humira® 40mg / 0.8ml pen Starter Dose: Sig: Inject contents of 2 pens (80mg) subcutaneously on Day 1, contents of 1 pen (40mg) on Day 8 and contents of 1 pen (40mg) on Day 22.

Dispense 4 pens No Refills

* Prescriber Authorization: I authorize this pharmacy and its representatives to act as my authorized agent to secure coverage and initiate the insurance prior authorization process for my patient(s), and to sign any necessary forms on my behalf as my authorized agent, including the receipt of any required prior authorization forms and the receipt and submission of patient lab values and other patient data. In the event that this pharmacy determines that it is unable to fulfill this prescription, I further authorize this pharmacy to forward this information and any related materials related to coverage of the product to another pharmacy of the patient’s choice or in the patient’s insurer’s provider network.

No Refills Dispense 24 pens Starter Dose: Inject 50mg subcutaneously twice weekly for three months

Enbrel® 50mg / ml SureClick AutoInjector

No Refills Dispense 2 syringes Sig: Inject contents of 1 syringe (45mg) subcutaneously on Day 0 and Day 28

Stelara® 45mg Prefilled Syringe

No Refills Sig: Inject contents of 1 syringe (90mg) subcutaneously on Day 0 and Day 28

Dispense 2 syringes Stelara® 90mg Prefilled Syringe

Dispense 2 pens (2 x 40mg) Sig: Inject contents of 1 pen (40mg) subcutaneously every other week Humira® 40mg / 0.8ml pen Refill x:

Dispense 4 vials Sig: Inject 25mg subcutaneously once weekly Enbrel® 25mg / ml Vial Refill x:

Dispense 4 syringes Sig: Inject contents of 1 pen (50mg) subcutaneously once weekly Enbrel® 50mg / ml SureClick AutoInjector Refill x:

Dispense 4 syringes Sig: Inject contents of 1 syringe (50mg) subcutaneously once weekly Enbrel® 50mg / ml Prefilled Syringe

Refill x:

Sig: Inject contents of 1 syringe (45mg) subcutaneously every 12 weeks

Stelara® 45mg Prefilled Syringe

Refill x:

Sig: Inject contents of 1 syringe (90mg) subcutaneously every 12 weeks

Stelara® 90mg Prefilled Syringe

Refill x:

Dispense 8 vials Sig: Inject 25mg subcutaneously twice weekly; 72–96 hours apart Enbrel® 25mg / ml Vial Refill x:

Patient Information

Last Name

First Name

DOB City

Home Address

Home Address 2

State Zip

Dispense 4 pens (4 x 40mg) Sig: Inject contents of 1 pen (40mg) subcutaneously once weekly Refill x:

Dermatology Biologics Therapy Prescription Form

Fax:

Phone:

060217

Prescriber’s Signature

Supervising physicianDate Date

Product Substitution permitted Dispense as Written