oncology - diplomatadult female not of reproductive potential adult female of reproductive potential...
TRANSCRIPT
Oncology Hematologic Cancer (drugs A-J) (Bosulif
®,
(Farydak®, Gleevec®, IDHIFA®, Imbruvica®, and Jakafi®)
Patient Information Prescriber + Shipping Information Patient name: ________________________ DOB: _____________ Sex: Female Male SSN: ______________________________ Language: ____________ Wt: _____ kg lbs Ht: _____cm in Address: _______________________________________________ Apt/Suite: _____ City: ________________ State: _____ Zip: ______ Phone: ___________________ Alternate: ____________________ Caregiver name: ____________________ Relation: _____________ Local pharmacy: _____________________ Phone: _____________ Insurance plan: _________________ Plan ID: ________________ Please fax a copy of front and back of the insurance card(s).
Prescriber name: _______________________________________ NPI: _________________________________________________ Address: ______________________________________________ Apt/Suite: ______ City: ____________ State: _______ Zip: ______ Contact: ______________________________________________ Phone: _____________________ Alternate: _________________Fax: _________________________________________________ Email: ________________________________________________ If shipping to prescriber: First Fill Always Never
Clinical Information (Please fax all pertinent clinical and lab information) Diagnosis (C00-D49): _____________________________________________________________ Diagnosis date: ________________Patient Type (if applicable): Adult female NOT of reproductive potential Adult female of reproductive potential Adult male Date: _____________________ Child female NOT of reproductive potential Child female of reproductive potential Child male Authorization: _______________Mutations: c-Kit Del 5q Del 17p FLT3 IDH2 PDGFR Ph+ Other Mutation ______________________Lymph Node size:_____ cm Absolute Lymphocyte count: _______/L TLS Risk: Low Moderate High Date:_________________
Reason for Discontinuation of Therapy Approximate Start Date Approximate End Date Prior Therapy Yes No ___________________________ ___________________________ ___________________________
__________________________________________________________________________________________________________________
___________________ ___________________ ___________________
___________________ ___________________ ___________________
Comorbidities:__________________________________________________________________________________________________ ConcomitantMedications: _________________________________________________________________________________________ Allergies: NKDA Other: _____________________________________________________________________________________ Prescription Quantity Refill
Bosulif®
(bosutinib) Take 500 mg by mouth once daily with food __________________________________________________________________
30 x 500 mg tablets _____________________
______
Farydak®
(panobinostat) Take 20 mg by mouth once daily on days 1, 3, 5, 8, 10 and 12 of a 21-day cycle
_________________________________________________________________
6 x 20 mg capsules
_____________________
______
Dexamethasone Take 20 mg by mouth once daily with food on days 1, 2, 4, 5, 8, 9, 11, and 12 of a
21-day cycle ___________________________________________________________________
8 x 20 mg capsules _____________________
______
Aspirin Take 81 mg by mouth once daily ___________________________________________________________________
28 x 81 mg tablets _____________________
______
Gleevec®
(imatinib)
Take 400 mg by mouth once daily with a meal and full glass of water Take 600 mg by mouth once daily with a meal and full glass of water Take _______ mg (340 mg/m2/day x _______ m2) by mouth once daily
with a meal and full glass of water _________________________________________________________________
30 x 400 mg tablets 30 x 400 mg tablets
60 x 100 mg tablets
_____________________
______
Imbruvica®
(ibrutinib)
Take 420 mg by mouth once daily with a full glass of water Take 560 mg by mouth once daily with a full glass of water _________________________________________________________________
90 x 140 mg capsules 120 x 140 mg capsules _____________________
______
Jakafi®
(ruxolitinib)
Take _______ mg by mouth once daily
Take _______ mg by mouth twice daily
30 x ____ mg tablets 60 x ____ mg tablets
______
§ Ninlaro®, Pomalyst®, Revlimid®, Rydapt®, Sprycel®, Synribo®, Tasigna®, Thalomid®, Venclexta™, Zolinza®, and Zydelig® are listed alphabetically on respective enrollment forms§
Per state-specific law, prescriptions will be dispensed as generic, if applicable, unless notated otherwise: __________________________________________
Prescriber’s Signature:_____________________________________________________________________________________ Date: ______________ I authorize Diplomat Pharmacy, Inc. and its representatives to act as an agent to initiate and execute the insurance prior authorization process for this prescription and any future fills of the same prescription for the patient listed above. I understand that I can revoke this designation at any time by providing written notice to Diplomat Pharmacy, Inc.
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Copyright © 2017 by Diplomat Pharmacy Inc. All rights reserved. Diplomat is a registered trademark of Diplomat Pharmacy Inc.
For patients requiring immune globulin therapy, please fill out the respective form: IVIg or SCIg.
Stamp signature not allowed, physician signature required.
IDHIFA®
(enasidenib)Take 100 mg by mouth once daily with a full glass of water _________________________________________________________________
30 x 100 mg tablets _____________________
______