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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 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 year _____

Heparin 10 units/mL Heparin 100 units/Ml IV

3 mL 5 mL _____________

After infusion _________________________________________


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)