Fillable Specialty Pharmacy Fertility Care Program Enrollment Form

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Specialty Pharmacy Fertility Care Program Enrollment Form

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Specialty Pharmacy Fertility Care Program Enrollment Form
Fax Referral To: 1-866-310-4139 Phone: 1-877-408-9742 Email Referral To: customerservicefax@caremark.com
Six Simple Steps to Submitting a Referral
1 PATIENT INFORMATION (Complete or include demographic sheet)
Patient Name: ____________________________Address: ________________________City, State, ZIP: __________________________
Preferred Contact Methods: Phone (to primary # provided below) Text (to cell # provided below) Email (to email provided below)
Note: Carrier charges may apply. If unable to contact via text or email, Specialty Pharmacy will attempt to contact by phone.
Primary Phone: ________________ Alternate Phone: ________________DOB: ________________ Gender: Male Female
Email: ____________________________________Last Four of SSN: ________________Primary Language: ______________________
2 PRESCRIBER INFORMATION
Prescriber’s Name: ____________________________________ State License #: _____________________________________________
NPI #: _______________ DEA #: _______________ Group or Hospital: ____________________________________________________
Address: _____________________________________________ City, State, ZIP: ____________________________________________
Phone: ___________________ Fax___________________ Contact Person: _________________ Contact’s Phone: _________________
3 INSURANCE INFORMATION Please fax copy of prescription and insurance cards with this form, if available (front and back)
4 CLINICAL INFORMATION
Needs by Date: ________ Ship to: Patient Office Other: ___________
Allergies: _________________________________________ Weight: ______lb/kg Height: ______in/cm
5 PRESCRIPTION INFORMATION
MEDICATION & STRENGTH
DOSE & DIRECTIONS
QUANTITY/REFILLS
Cetrotide
®
0.25 mg Syringe
Other: _________________________________
Quantity: ____ Refills: ____
Ganirelix
®
250 mcg/0.5mL
Other: _________________________________
Quantity: ____ Refills: ____
Leuprolide 2 Week Kit
Other: _________________________________
Quantity: ____ Refills: ____
Leuprolide Micro Dose _____ mcg / _____ mL
Other: _________________________________
Quantity: ____ Refills: ____
Follistim
®
AQ 300 IU Cartridge
Other: _________________________________
Quantity: ____ Refills: ____
Follistim AQ 600 IU Cartridge
Other: _________________________________
Quantity: ____ Refills: ____
Follistim AQ 900 IU Cartridge
Other: _________________________________
Quantity: ____ Refills: ____
Follistim Pen
®
Other: _________________________________
Quantity: ____ Refills: ____
Gonal-F
®
450 IU MDV
Other: _________________________________
Quantity: ____ Refills: ____
Gonal-F 1050 IU MDV
Other: _________________________________
Quantity: ____ Refills: ____
Gonal-F RFF 75 IU Vial
Other: _________________________________
Quantity: ____ Refills: ____
Gonal-F RFF Rediject
TM
300 IU Pen
Other: _________________________________
Quantity: ____ Refills: ____
Gonal-F RFF Rediject 450 IU Pen
Other: _________________________________
Quantity: ____ Refills: ____
Gonal-F RFF Rediject 900 IU Pen
Other: _________________________________
Quantity: ____ Refills: ____
Menopur
®
75 IU Vial
Other: _________________________________
Quantity: ____ Refills: ____
HCG Low Dose _____ Units / _____ mL Vial
Other: _________________________________
Quantity: ____ Refills: ____
HCG 10,000 Unit Vial
Other: _________________________________
Quantity: ____ Refills: ____
Novarel
®
5,000 Unit Vial
Other: _________________________________
Quantity: ____ Refills: ____
Pregnyl
®
10,000 Unit Vial
Other: _________________________________
Quantity: ____ Refills: ____
Ovidrel
®
250 mcg / 0.5 mL
Other: _________________________________
Quantity: ____ Refills: ____
Crinone
®
8% Gel
Other: _________________________________
Quantity: ____ Refills: ____
Endometrin
®
100 mg
Other: _________________________________
Quantity: ____ Refills: ____
Prometrium
®
_____ mg
Other: ___________________________________
Quantity: ____ Refills: ____
Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED Ancillary supplies and kits provided as needed for administration
6 PHYSICIAN SIGNATURE REQUIRED
PRODUCT SUBSTITUTION PERMITTED
(Date)
x_______________________________________
DISPENSE AS WRITTEN (Date)
x______________________________________
The information provided above is true and accurate to the best of my knowledge, with supporting documentation in the patient’s medical record. By signing below, I hereby
authorize CVS Specialty Pharmacy and/or its affiliate pharmacies to complete and submit prior authorization (PA) requests to payors for the prescribed medication for this patient
and to attach this Enrollment Form to the PA request as my signature.
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
Specialty and/or one of its affiliates.
©2018 CVS Specialty and/or one of its affiliates. 75-42400A 112118
Phone: 404-528-1728
Fax Referral To: 844-364-9364
Address: 2700 Northeast Expressway NE Suite B-800, Atlanta, GA 30345
Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED Ancillary supplies and kits provided as needed for administration
6 PHYSICIAN SIGNATURE REQUIRED
PRODUCT SUBSTITUTION PERMITTED (Date)
x_______________________________________
DISPENSE AS WRITTEN (Date)
x______________________________________
Continued
Specialty Pharmacy Fertility Care Program Enrollment Form
Please complete Patient and Prescriber information
Patient Name: ________________________________ Patient DOB: ________________________________
Prescriber Name: _____________________________ Prescriber Phone: ____________________________
5aPRESCRIPTION INFORMATION
MEDICATION & STRENGTH
DOSE & DIRECTIONS
QUANTITY/REFILLS
Progesterone Compounded Capsules _____ mg
Other: _____________________________________
Quantity: _____ Refills: _____
Progesterone Suppositories ____ mg
Other: _____________________________________
Quantity: _____ Refills: _____
Progesterone / Sesame Oil 50 mg / mL Vial
Other: _____________________________________
Quantity: _____ Refills: _____
Progesterone( ____) 50 mg / mL Vial
Other: _____________________________________
Quantity: _____ Refills: _____
Delestrogen
®
_____ mg / mL
Other: _____________________________________
Quantity: _____ Refills: _____
Syringe 1 mL only
Other: _____________________________________
Quantity: _____ Refills: _____
Syringe 3 mL only
Other: _____________________________________
Quantity: _____ Refills: _____
Syringe 3 mL 18g 1.5”
Other: _____________________________________
Quantity: _____ Refills: _____
Syringe 3 mL 22g 1.5”
Other: _____________________________________
Quantity: _____ Refills: _____
Needle 18 g 1.5”
Other: _____________________________________
Quantity: _____ Refills: _____
Needle 22 g 1.5”
Other: _____________________________________
Quantity: _____ Refills: _____
Needle 25 g 1.5”
Other: _____________________________________
Quantity: _____ Refills: _____
Needle 25 g 5/8”
Other: _____________________________________
Quantity: _____ Refills: _____
Needle 27 g 0.5”
Other: _____________________________________
Quantity: _____ Refills: _____
Needle 30 g 0.5”
Other: _____________________________________
Quantity: _____ Refills: _____
Insulin Syringe ____ mL
Other: _____________________________________
Quantity: _____ Refills: _____
Aspirin 81 mg
Other: _____________________________________
Quantity: _____ Refills: _____
Azithromycin _____ mg
Other: _____________________________________
Quantity: _____ Refills: _____
Cabergoline 0.5 mg
Other: _____________________________________
Quantity: _____ Refills: _____
Citranatal
®
_______________
Other: _____________________________________
Quantity: _____ Refills: _____
Clomiphene 50 mg
Other: _____________________________________
Quantity: _____ Refills: _____
Dexamethasone _____ mg
Other: _____________________________________
Quantity: _____ Refills: _____
Doxycycline 100 mg
Other: _____________________________________
Quantity: _____ Refills: _____
Estradiol ____ mg
Other: _____________________________________
Quantity: _____ Refills: _____
Folic Acid 1 mg
Other: _____________________________________
Quantity: _____ Refills: _____
Letrozole 2.5 mg
Other: _____________________________________
Quantity: _____ Refills: _____
Methylprednisolone _____ mg
Other: _____________________________________
Quantity: _____ Refills: _____
Prednisone _____ mg
Other: _____________________________________
Quantity: _____ Refills: _____
Prenatal Plus
Other: _____________________________________
Quantity: _____ Refills: _____
Z-Pak
®
250 mg #6 Tablets
Other: _____________________________________
Quantity: _____ Refills: _____
Climara
®
0.1 mg Patch
Other: _____________________________________
Quantity: _____ Refills: _____
Minivelle
®
0.1 mg Patch
Other: _____________________________________
Quantity: _____ Refills: _____
Vivelle DOT
®
0.1 mg Patch
Other: _____________________________________
Quantity: _____ Refills: _____
Heparin _____ units / mL Vial
Other: _____________________________________
Quantity: _____ Refills: _____
Lovenox
®
_____ mg Syringes
Other: _____________________________________
Quantity: _____ Refills: _____
Other: _________________________________
Other: _____________________________________
Quantity: _____ Refills: _____
Other: _________________________________
Other: _____________________________________
Quantity: _____ Refills: _____
Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED Ancillary supplies and kits provided as needed for administration
6 PHYSICIAN SIGNATURE REQUIRED
PRODUCT SUBSTITUTION PERMITTED
(Date)
x_______________________________________
DISPENSE AS WRITTEN (Date)
x______________________________________
The information provided above is true and accurate to the best of my knowledge, with supporting documentation in the patient’s medical record. By signing below, I hereby
authorize CVS Specialty Pharmacy and/or its affiliate pharmacies to complete and submit prior authorization (PA) requests to payors for the prescribed medication for this patient
and to attach this Enrollment Form to the PA request as my signature.
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
Specialty and/or one of its affiliates.
©2018 CVS Specialty and/or one of its affiliates. 75-42400A
112118
Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED Ancillary supplies and kits provided as needed for administration
6 PHYSICIAN SIGNATURE REQUIRED
PRODUCT SUBSTITUTION PERMITTED (Date)
x_______________________________________
DISPENSE AS WRITTEN (Date)
x______________________________________
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Specialty Pharmacy Fertility Care Program Enrollment Form

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Completed 3 November 2021

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