Fillable Cystic Fibrosis Referral Form (Kroger)

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Cystic Fibrosis Referral Form (Kroger)

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Fax Copy: Rx Card Front/Back Clinical Notes Medical Card Front/Back
_________________________________________________________ ________________ _________________________________________________________ _________________
Prescriber’s Signature (no stamps) Substitution Permitted Date Prescriber’s Signature (no stamps) Dispense As Written Date
Cystic Fibrosis
OFL-2890-090120-2005
Orlando, FL toll free 855.274.1694 dedicated CF fax 844.306.0200 krogerspecialtypharmacy.com
Prescriber Information
Prescriber Name Supervising MD NPI
Address City State Zip
Phone Fax
DEA # NPI # License #
Clinical Information
CFTR Mutation FEV Weight kg lbs
Diagnosis: E84.0 Cystic Fibrosis with Pulmonary Manifestations E84.9 Cystic Fibrosis Unspecified E84.11 Mecoium Ileus in Cystic Fibrosis
E84.19 Cystic Fibrosis with Intestinal Manifestations E84.8 Cystic Fibrosis with Other Manifestations B96.5 Pseudomonas (Mallei) Causing Diseases
Other: ________________________________________________________________________________________________________________________________________
Drug Allergies
Med Dose/Strength Directions (Frequency of Administration) Qty Rells
CFTR Potentiator: Please Complete GPS Enrollment Form and Fax to Kroger Specialty Pharmacy with RX ref
Kalydeco®
List mutations:
150mg Tablet
25mg Oral Granules (5kg to <7kg)
50mg Oral Granules (7kg to <14kg)
75mg Oral Granules (≥14kg)
po q 12h (age 6 and older) with fat-containing food
po q 12h (6 mos-5 yrs) mixed with 1 tsp (5mL) of soft food/liquid with fat-containing food
po q 12h (6 mos-5 yrs) mixed with 1 tsp (5mL) of soft food/liquid with fat-containing food
po q 12h (6 mos-5 yrs) mixed with 1 tsp (5mL) of soft food/liquid with fat-containing food
28-Day
84-Day
Orkambi®
(Pediatric)
F508del: Yes No
100-125mg Oral Granules (<14kg)
150-188mg Oral Granules (≥14kg)
100mg/125mg Tablets
po q 12h (ages 2-5, <14kg) mixed with 1 tsp (5mL) of soft food/liquid with fat-containing food
po q 12h (ages 2-5, ≥14kg) mixed with 1 tsp (5mL) of soft food/liquid with fat-containing food
2 Tablets po q 12h (ages 6-11) with fat-containing food
28-Day
84-Day
Orkambi®
F508del: Yes No
200mg/125mg Tablets 2 Tablets po q 12h (age 12 and older) with fat-containing food 28-Day
84-Day
Symdeko®
F508del: Yes No
100-150mg/150mg Tablets 1 Tablet (tezacaftor 100mg/ivacaftor 150mg) po in the morning with with fat-containing
food; 1 Tablet (ivacaftor 150mg) in the evening with fat-containing food, approximately 12
hours after the morning dose
28-Day
84-Day
Symdeko®
(Pediatric)
F508del: Yes No
50-75mg/75mg Tablets 1 Tablet (tezacaftor 50mg/ivacaftor 75mg) po in the morning with fat-containing food;
1 Tablet (ivacaftor 75mg) in the evening with fat-containing food, approximately 12 hours
after the morning dose (age 6-11 yrs <30kg)
28-Day
84-Day
Trikafta
TM
100mg/50mg/75mg and 150mg Tablets 2 Orange tablets po in the morning and 1 blue tablet in the evening, 12 hours apart with
fat-containing food (age 12 and older)
28-Day
84-Day
Pancreatic Enzymes
Creon® 3,000 u 6,000 u 12,000 u 24,000 u 36,000 u # of caps per meals: ________ # of caps per snacks: ________ Daily Max: ________
Please advise # of consumed meals and snacks per day (i.e. 3 meals and 2 snacks per day):
Pancreaze® 2,600 u 4,200 u 10,500 u 16,800 u 21,000 u
Pertzye® 4,000 u 8,000 u 16,000 u 24,000 u
Viokace® 10,440 u 20,880 u
Zenpep® 3,000 u 5,000 u 10,000 u 15,000 u
20,000 u 25,000 u 40,000 u
RELiZORB®
Cartridge
1 Cartridge/Day (500mL) Dispense 30 Ea/Cartridge
2 Cartridges/Day (1000mL) Dispense 60 Ea/Cartridge
Use 1 Cartridge in-line with enteral feeding tube set, change cartridge with every
500mL of enteral formula (max of 2 cartridges used per day)
Inhaled Enzymes
Pulmozyme® 2.5mg/2.5mL amp Select One: Once Daily Twice Daily
Vitamins
AquaDEKs
TM
Chew Tab Liquid
Calcium Carbonate 1250mg (500mg)
DEKAS Essentials Capsule Liquid
DEKAS Plus Chew Tab Liquid Soft Gels
MVW Complete Chew Tab Drops Soft Gels D3000 D5000
MVW 400 u 1,000 u 2,000 u 5,000 u 50,000 u
Oral Antibiotics
Azithromycin
Bactrim DS
Linezolid
GI
PEG 3350/Miralax
Esomeprazole
Famotidine
Lansoprazole
Omeprazole
Pantoprazole
Zegerid (OMEP/SodBic)
Patient Information
Patient Name Date of Birth Male Female
Address City State Zip
Phone Social Security #
Parent/Guardian Name
By signing this form and utilizing our services, you are authorizing Kroger® Specialty Pharmacy and its employees to serve as your prior authorization designated agent in dealing with medical and prescription insurance companies.
IMPORTANT NOTICE: This fax is intended to be delivered only to the named addressee. It contains material that is confidential, privileged property or exempt from disclosure under applicable law. If you are not the named addressee
you should not disseminate, distribute or copy this fax. Please notify the sender immediately if you have received this document in error and then destroy this document immediately.
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Cystic Fibrosis Referral Form (Kroger)

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Completed 12 September 2020

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