Section 3. Prescriber Information
Prescriber name _______________________________________________________ Site/facility name ________________________________________
__
_______________
Prescriber NPI # ________________________________________________
__
_______ Ofce contact name ______________________________________________________
Specialty_______________________________________________________________ Ofce contact email ______________________________________________________
Address ____________________________________________________
_
_________ Phone (_______) _________________________________________________________
City ________________________________________ State _______ ZIP _____
__
__ Fax (_______) ___________________________________________________________
Prescriber to Fill Out
1
Moderate-to-severe
atopic dermatitis
Section
2. Insurance Information
Primary medical insurance name _____________________________________
___
___
Insurance phone (_______) _______________________________________________
Policy ID # ___________________________ Group # ____________________________
Policyholder name (rst/last) _______________________________________________
Relationship to patient ____________________________________________________
Primary Rx insurance name (if different) ______________________________________
Rx insurance phone (_______) _______________________________________________
Policy ID # ____________________________ Group # _____________________________
Rx BIN #_____________________________ Rx PCN # ____________________________
No insurance (Fill out Section 6 if you do not have health insurance.) Attached copies of front and back of primary medical and prescription cards.
Section 5. Prescription Information
Prescription: New start Sample product provided Date ______/______/________
I have already sent this prescription to the specialty pharmacy.
By checking the box, I acknowledge DUPIXENT MyWay will not conduct a benets verication. The specialty pharmacy is responsible for securing coverage on my patient’s behalf.
My preferred specialty pharmacy is _______________________
____
______________ Phone (_______) ______________________ Fax (_______) ___
______________
____
_________________________________________________________________________________
Prescriber signature (No stamps) Dispense as written
Date
Sign
OR
_________________________________________________________________________________
Prescriber signature (No stamps) Substitution permitted
Date
Sign
Collaborating MD name (Nurse practitioner/physician assistant)_________________________________________________________________________ NPI # _______________________________________
Patient to Fill Out
Section 1. Patient Information
Patient name (rst, MI, last) _______________________________________________________________________ DOB _________________________ Gender
F
M
Address __________________________________________________________________________ City __________________________________________________________
State _________________________________ ZIP _____________ Preferred patient language (if not English) _______________________________________________________
Mobile phone (_______)________________________ Preferred # Voicemail Alternate phone (_______)______________________ Preferred #
Voicemail
Best time to call
8 –10 am 10am–12 pm 12–2pm 2–4pm 4–6pm 6–9pm
Email ___________________________________________________________________
Patient Authorization
I have read and agree to the Patient Authorization to Use and Disclose Health Information included in Section 7.
________________________________________________________________________________________
(1 of 2) Patient signature/Legal representative if patient is <18 years
Date
I have read and agree to the Patient Certications included in Section 8.
_____________________________________________________________________________________
(2 of 2) Patient signature/Legal representative if patient is <18 years
Date
Sign
_______________________________________________________________ _____________________________________________________________
If patient is <18 years, print name if signed by legal representative If patient is <18 years, insert representative's relationship to patient
Sign
I have read the Text Messaging Consent in Section 8 and expressly consent to
receive text messages by or on behalf of the Program.
Enrollment Form
Complete entire form and fax ALL 4 PAGES to DUPIXENT MyWay
®
at 1-844-387-9370.
To prevent delays, complete the entire form and fax it to the number above. For assistance,
call 1-844-DUPIXEN(T) (1-844-387-4936) Option 1, Monday–Friday, 8 am–9 pm Eastern time.
Please see accompanying full Prescribing Information or visit DUPIXENThcp.com.
DUP.20.03.0321
My signature certies that the person named on this form is my patient; the information provided on this application, to the best of my knowledge, is complete and accurate; that therapy with DUPIXENT is medically necessary; and that I have prescribed DUPIXENT to the patient
named on this form for an FDA-approved indication. I understand that my patient’s information provided to Regeneron Pharmaceuticals, Inc., Sano US, and their afliates and agents (the “Alliance”) is for the use of DUPIXENT MyWay solely to verify my patient’s insurance
coverage; to assess, if applicable, my patient’s eligibility for patient assistance and other support programs; and to otherwise administer DUPIXENT MyWay for the patient. I certify that I have obtained my patient’s written authorization in accordance with applicable state and federal
law, including the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, to provide the individually identiable health information on this form to reimbursement support programs such as DUPIXENT MyWay for these purposes. If applicable,
I authorize DUPIXENT MyWay to conduct a benets investigation for my patient and to act on my behalf for the limited purpose of transmitting this prescription to the appropriate pharmacy designated by the patient per their benet plan provided that, if this prescription is not so
designated, DUPIXENT MyWay is authorized to transmit this prescription to a network pharmacy it selects or to the pharmacy otherwise indicated. I understand that any free product distributed through the DUPIXENT MyWay Patient Assistance Program is not contingent on
any purchase obligations. I also understand that no free product may be submitted for reimbursement to any payer, including Medicare and Medicaid; and no free product may be sold, traded, or distributed for sale. I consent to DUPIXENT MyWay contacting me
by fax, mail, or email to provide additional information about DUPIXENT injection or DUPIXENT MyWay. I understand that DUPIXENT MyWay may revise, change, or terminate any program services at any time without notice to me.
If you are a New York prescriber, please use an original New York State prescription form. The prescriber is to comply with his/her state-specic prescription requirements, such as e-prescribing, state-specic
prescription form, fax language, etc. Non-compliance with state-specic requirements could result in outreach to the prescriber.
Please see full indication on next page. ICD-10-CM=International Classication of Diseases, Tenth Revision, Clinical Modication.
Section 4. Diagnosis
Moderate-to-severe atopic dermatitis ICD-10-CM code(s):
L20.9 Atopic Dermatitis, unspecied L20.89 Other Atopic Dermatitis Other _____________________
See the list of potential ICD-10-CM codes on page 2. Attach any chart notes relevant to diagnosis and current/prior therapies.
Date of diagnosis ______/______/________
Rx: DUPIXENT
®
(dupilumab) (200 mg/1.14 mL, 300 mg/2 mL)
Known drug allergies ___________________________________________________________________________________________________________________
Adult patients aged ≥18 years Pre-lled syringe, package of 2
Initial dose: 600 mg Subsequent (maintenance) dose: 300 mg
SIG: 2 (300 mg/2 mL) injections SQ on Day 1 SIG: 1 (300 mg/2 mL) injection SQ every 2 weeks, starting on Day 15
OR
Pediatric patients aged 6-17 years: Weight: _______ kg (1 kg=2.2 lb) Pre-lled syringe, package of 2
Weight 15 to <30 kg:
Initial dose: 600 mg Subsequent (maintenance) dose: 300 mg
SIG: 2 (300 mg/2 mL) injections SQ on Day 1 SIG: 1 (300 mg/2 mL) injection SQ every 4 weeks, starting on Day 29
Weight 30 to <60 kg:
Initial dose: 400 mg Subsequent (maintenance) dose: 200 mg
SIG: 2 (200 mg/1.14 mL) injections SQ on Day 1 SIG: 1 (200 mg/1.14 mL) injection SQ every 2 weeks, starting on Day 15
Weight ≥60 kg:
Initial dose: 600 mg Subsequent (maintenance) dose: 300 mg
SIG: 2 (300 mg/2 mL) injections SQ on Day 1 SIG: 1 (300 mg/2 mL) injection SQ every 2 weeks, starting on Day 15
OR
Subsequent (maintenance): Other
Dose ______________________________________ SIG _______________________________________
Qty: 1 pk
(2 syringes)
Rells _________
Days’ supply:
30
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