IGIV Caremark Only …... ttttttttttt, [:58:>-,,, w6
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CONFIDENTIALITY NOTICE: This communication and any attachments may contain confidential and/or privileged information for the use of the designated recipients named above. If you are not the intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please notify the sender immediately by telephone and destroy all copies of this communication and any attachments. Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members’ private health information. This document contains references to brandname prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS/caremark ® . 7535800 100915 Immune Globulins (Ig) Enrollment Form Fax Referral To: 18668433221 Phone: 18668991661 Email Referral To: [email protected] Six Simple Steps to Submitting a Referral PATIENT INFORMATION (Complete or include demographic sheet) PRESCRIBER INFORMATION Patient Name: ______________________________________ Prescriber’s Name: ______________________________________ Address: ______________________________________ State License #: ______________ NPI #: ______________ City, State, ZIP: ______________________________________ DEA #: ______________ Preferred Contact Method: Phone (to primary # provided below) Text (to cell # provided below) Email (to email provided below) Group or Hospital: ______________________________________ Note: Carrier charges may apply. If unable to contact via text or email, Specialty Pharmacy will attempt to contact by phone. Address: ______________________________________ Primary Phone: ___________ Home Cell Work City, State, ZIP: ______________________________________ Alternate Phone: ___________ Home Cell Work Phone: ______________________________________ DOB: ___________ Gender: Male Female Fax: ______________________________________ Email: ______________________________________ Contact Person: ______________________________________ Last Four of SSN: ___________ Primary Language: _________ Contact’s Phone: ______________________________________ INSURANCE INFORMATION Please fax copy of prescription and insurance cards with this form, if available (front and back) DIAGNOSIS AND CLINICAL INFORMATION Needs by Date: ______________ Ship to: Patient Office Other: __________ Diagnosis (ICD10): D80.0 Congenital Hypogammaglobulinemia D81.9 SCID (Unspecified) D83.9 Common Variable Immunodeficiency G35 MS (Relapsing Remitting) G61.0 GBS G61.81 CIDP G61.89 MMN G70.00 MG without acute exacerbation G70.01 MG with acute exacerbation M33.20 Polymyositis M33.90 Dermatomyositis Other Code: _________________ Description: _______________________________ For additional ICD10 information, please visit www.CVSspecialty.com/ICD10 Patient Clinical Information: Allergies: _____________________________ Weight: __________________ lb/kg Height: _______________________ in/cm Lab Orders: _________________________________________________________________________________________________________________ Nursing: Please arrange nursing for administration Patient may be taught to selfinfuse PRESCRIPTION INFORMATION MEDICATION ROUTE DOSE/STRENGTH DIRECTIONS QUANTITY REFILLS Immune Globulin ______________________ SC IV IM ________ grams ________ mg/kg 1 month 3 months ________ 1 year _____ Normal Saline D5W IV 3 mL 5 mL _____________ Before and after infusion _________________________________________ 1 month 3 months ________ 1 year _____ Heparin 10 units/mL Heparin 100 units/Ml IV 3 mL 5 mL _____________ After infusion _________________________________________ 1 month 3 months ________ 1 year _____ Diphenhydramine PO IV IM 25 mg 50 mg _____________ PreMed: _________________________________ PRN Allergic Reaction: ______________________ _________________________________________ _________________________________________ With each infusion ________ 1 year _____ Acetaminophen PO 325 mg 500 mg 650 mg 1 gm _____________ PreMed: _________________________________ _________________________________________ With each infusion ________ 1 year _____ Epinephrine IM SQ Adult 1:1000, 0.3 mL (>30kg/>66lbs) Peds 1:2000, 0.3 mL (1530 kg/3366 lbs) PRN Anaphylaxis Repeating Dose: __________________________ _________________________________________ Once ________ 1 year _____ Other: ____________ Vascular Access Method peripheral central other _______________________________________ Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED Ancillary supplies and kits provided as needed for administration x___________________________________ x___________________________________ PRODUCT SUBSTITUTION PERMITTED (Date) DISPENSE AS WRITTEN (Date) Phone: 1-866-899-1661 Fax Referral To: 1-866-843-3221 Email Referral To: [email protected] Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED Ancillary supplies and kits provided as needed for administration x_________________________________________ x__________________________________________ PRODUCT SUBSTITUTION PERMITTED (Date) DISPENSE AS WRITTEN (Date) Phone: 1-866-899-1661 Fax Referral To: 1-866-843-3221 Email Referral To: [email protected] Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED Ancillary supplies and kits provided as needed for administration x_________________________________________ x__________________________________________ PRODUCT SUBSTITUTION PERMITTED (Date) DISPENSE AS WRITTEN (Date)
Transcript of IGIV Caremark Only …... ttttttttttt, [:58:>-,,, w6
CONFIDENTIALITY NOTICE: This communication and any attachments may contain confidential and/or privileged information for the use of the designated recipients named above. If you are not the intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please notify the sender immediately by telephone and destroy all copies of this communication and any attachments. Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members’ private health information. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS/caremark®. 75-35800 100915
Immune Globulins (Ig) Enrollment Form Fax Referral To: 1-866-843-3221 Phone: 1-866-899-1661 Email Referral To: [email protected]
Six Simple Steps to Submitting a Referral uPATIENT INFORMATION (Complete or include demographic sheet) v PRESCRIBER INFORMATION Patient Name: ______________________________________ Prescriber’s Name: ______________________________________ Address: ______________________________________ State License #: ______________ NPI #: ______________ City, State, ZIP: ______________________________________ DEA #: ______________ Preferred Contact
Method: Phone
(to primary # provided below) Text
(to cell # provided below) Email
(to email provided below) Group or Hospital: ______________________________________ Note: Carrier charges may apply. If unable to contact via text or email, Specialty Pharmacy will attempt to contact by phone. Address: ______________________________________
Primary Phone: ___________ Home Cell Work City, State, ZIP: ______________________________________ Alternate Phone: ___________ Home Cell Work Phone: ______________________________________ DOB: ___________ Gender: Male Female Fax: ______________________________________ Email: ______________________________________ Contact Person: ______________________________________ Last Four of SSN: ___________ Primary Language: _________ Contact’s Phone: ______________________________________
wINSURANCE INFORMATION Please fax copy of prescription and insurance cards with this form, if available (front and back)
xDIAGNOSIS AND CLINICAL INFORMATION Needs by Date: ______________ Ship to: Patient Office Other: __________ Diagnosis (ICD-10):
D80.0 Congenital Hypogammaglobulinemia D81.9 SCID (Unspecified) D83.9 Common Variable Immunodeficiency G35 MS (Relapsing Remitting) G61.0 GBS G61.81 CIDP G61.89 MMN G70.00 MG without acute exacerbation G70.01 MG with acute exacerbation
M33.20 Polymyositis M33.90 Dermatomyositis Other Code: _________________ Description: _______________________________
For additional ICD-10 information, please visit www.CVSspecialty.com/ICD10 Patient Clinical Information: Allergies: _____________________________ Weight: __________________ lb/kg Height: _______________________ in/cm Lab Orders: _________________________________________________________________________________________________________________ Nursing: Please arrange nursing for administration Patient may be taught to self-infuse
�PRESCRIPTION INFORMATION MEDICATION ROUTE DOSE/STRENGTH DIRECTIONS QUANTITY REFILLS
Immune Globulin ______________________
SC IV IM
________ grams ________ mg/kg
1 month 3 months ________
1 year _____
Normal Saline D5W IV
3 mL 5 mL _____________
Before and after infusion _________________________________________
1 month 3 months ________
1 year _____
Heparin 10 units/mL Heparin 100 units/Ml IV
3 mL 5 mL _____________
After infusion _________________________________________
1 month 3 months ________
1 year _____
Diphenhydramine PO IV IM
25 mg 50 mg _____________
Pre-Med: _________________________________ PRN Allergic Reaction: ______________________
_________________________________________ _________________________________________
With each infusion ________
1 year _____
Acetaminophen PO 325 mg 500 mg 650 mg 1 gm _____________
Pre-Med: _________________________________ _________________________________________
With each infusion ________
1 year _____
Epinephrine IM SQ
Adult 1:1000, 0.3 mL (>30kg/>66lbs) Peds 1:2000, 0.3 mL
(15-30 kg/33-66 lbs)
PRN Anaphylaxis Repeating Dose: __________________________
_________________________________________
Once ________
1 year _____
Other: ____________
Vascular Access Method peripheral central other _______________________________________ Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED Ancillary supplies and kits provided as needed for administration zx___________________________________ x___________________________________ PRODUCT SUBSTITUTION PERMITTED (Date) DISPENSE AS WRITTEN (Date)
Phone: 1-866-899-1661Fax Referral To: 1-866-843-3221Email Referral To: [email protected]
Caremark OnlyIGIV
Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED Ancillary supplies and kits provided as needed for administration
x_________________________________________ x__________________________________________ PRODUCT SUBSTITUTION PERMITTED (Date) DISPENSE AS WRITTEN (Date)
Phone: 1-866-899-1661Fax Referral To: 1-866-843-3221Email Referral To: [email protected]
Caremark OnlyIGIV
Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED Ancillary supplies and kits provided as needed for administration
x_________________________________________ x__________________________________________ PRODUCT SUBSTITUTION PERMITTED (Date) DISPENSE AS WRITTEN (Date)
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