Fillable Specialty Pharmacy Intake Form

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Specialty Pharmacy Intake Form

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Specialty Pharmacy Intake Form
Please see Repatha
®
Indications and Important Safety Information on page 3.
If an item does not apply, please note “N/A” on that line.
Fax with copies of insurance card(s), front and back, and appropriate information from
patient's medical charts to the Specialty Pharmacy you have indicated below.
© 2019 Amgen Inc. All rights reserved.
USA-145-80884
Patient Information
Patient Name*:
Street Address*:
City*: State*: Zip*:
Preferred Phone*: ( )
Email Address:
Date of Birth*:
Social Security Number:
Pharmacy Insurance Information Primary/Secondary Medical Insurance Information
(ONLY if Pharmacy Insurance Information is not available)
Attach a copy of pharmacy insurance card, front a
nd back, AND provide:
Pharmacy Insurance ID #*:
Pharmacy Insurance Telephone*: ( )
Attach a copy of insurance card, front and back, AND provide:
Name of Insurer*:
Insurer Telephone: ( )
Group Number:
Policy Number*:
Prescriber Information
Office Contact:
Email Address:
Prescriber Name*:
Specialty:
State License Number:
Office Street Address*:
City*: State*: Zip*:
Office Name*:
Telephone*: ( ) Fax: ( )
Prescriber NPI #*:
Tax ID
#:
Prescription Information: Repatha
®
FORMULATION AND DIRECTIONS (Choose one):
Inject 140-mg/mL subcutaneously using a SureClick
®
autoinjector every two (2) weeks
†
DISPENSED QUANTITY FOR:
28 days 84 days ____ days
REFILLS:
_______ refills
Administer 420-mg/3.5 mL subcutaneously using a Pushtronex
®
system (on-body
infusor with prefilled cartridge) once (1) monthly
‡
30 days 90 days ____ days
_______ refills
I authorize Amgen and its agents to act on my behalf for the limited purposes of transmitting this prescription to the appropriate pharmacy
consistent with the patient's benefit plan.
Prescriber Signature (no stamps) X_________________________________ X__________________________________ Date: ________________
Specialty Pharmacy Instructions
Fax with copies of insurance card(s), front and back, and appropriate information from
patient's medical charts to the Specialty Pharmacy of your preference.
Specialty Pharmacy Name:
* Required for processing.
†
Dosage for primary hyperlipidemia indication, including HeFH indication. The needle cover of the single-use prefilled autoinjector contains dry natural rubber (a derivative of latex) that
may cause allergic reactions in individuals sensitive to latex.
‡
Dosage for primary hyperlipidemia indication, including HeFH, or for HoFH indications. The single-use on-body infusor with prefilled cartridge is not made with natural rubber latex.
Repatha
®
is a trademark of Amgen Inc. All other marks used herein are the property of their respective owners.
By signing above, you represent that your patient is aware of the disclosure of their personal health information to the Specialty Pharmacy for insurance verification services and to Amgen
and its agents for Amgen's patient support services, including the services provided by field reimbursement professionals in your office, as part of the patient's treatment with this product and that
you have obtained appropriate patient authorizations as needed.
I understand that the Specialty Pharmacy may receive remuneration from Amgen in exchange for disclosing my personal health information and/or for using my
information to contact me with communications about Amgen products that have been prescribed to me (for example, adherence programs) and other
patient support services.
Substitution allowedDispense as written
Phone: Fax:
click to sign
signature
click to edit
© 2019 Amgen Inc. All rights reserved.
USA-145-80884
* Required for processing.
†
The sample diagnosis codes are informational and not intended to be directive or a guarantee of reimbursement, and include potential codes that would include FDA-approved
indications for Repatha
®
. Other codes may be more appropriate given internal system guidelines, payer requirements, practice patterns, and the services rendered.
Fax Completed Form and/or Copy of Insurance Card(s), Front and Back, to the Specialty Pharmacy of your preference.
Repatha
®
and Repatha
Ready
®
are trademarks of Amgen Inc. All other marks used herein are the property of their respective owners.
Patient Medical Information
Please provide one primary and one secondary established CVD ICD-10-CM code*
,†
:
Primary Codes:
E78.00 Pure Hypercholesterolemia,
unspecified
E78.01 Familial
Hypercholesterolemia
E78.2 Mixed Hyperlipidemia
E78.4 Other Hyperlipidemia
E78.5 Hyperlipidemia, Unspecified
Secondary Codes:
I20.0 Unstable Angina
I20.9 Angina Pectoris,
Unspecified
I21.
Acute Myocardial
Infarction
I22.
Subsequent
Myocardial
Infarction
I25.
Chronic Ischemic
Heart Disease
I63. Cerebral Infarction
I65.
Occlusion and
Stenosis of Cerebral
Arteries, Extracranial
I66.
Occlusion and
Stenosis of Cerebral
Arteries, Intracranial
I67. Other
Cerebrovascular
Diseases
I70.
Atherosclerosis
I73.9 Peripheral Vascular Disease,
Unspecified
G45.9 Transient Cerebral Ischemic
Attack, Unspecified
G46. Vascular Syndromes
Z83.42 Family history of familial
hypercholesterolemia
Other (specify ICD-10-CM):
Lipid-lowering Treatment History (select all that apply)
LDL-C on treatment:
Date of Lab: [ / / ] LDL-C on Repatha
®
(if applicable) Date of Lab: [ / / ]
Atorvastatin (Lipitor
®
) 10mg 20mg 40mg 80mg Date of Initiation [ / / ] Treatment End Date [ / / ]
Achieved maximum tolerated statin dose? Y N
Rosuvastatin (Crestor
®
) 5mg 10mg 20mg 40mg Date of Initiation [ / / ] Treatment End Date [ / / ]
Achieved maximum tolerated statin dose? Y N
Simvastatin (Zocor
®
) 5mg 10mg 20mg 40mg Date of Initiation [ / / ] Treatment End Date [ / / ]
Achieved maximum tolerated statin dose? Y N
Other statin/lipid-lowering medication(s):
Date of Initiation [ / / ] Treatment End Date [ / / ]
Achieved maximum tolerated statin dose? Y N
Ezetimibe (Zetia
®
) Date of Initiation [ / / ] Treatment End Date [ / / ] Added to statin? Y N
Indicate statin: Dose (mg) [ ]
Repatha
®
was prescribed by, or in consultation with, a cardiologist, an endocrinologist, and/or a physician who focuses on the management of
cardiovascular disease and/or lipid disorders.
Has the patient failed on or do they have
contraindications to any of the above therapies?
Other pertinent medical history or drug therapy:
History of atherosclerotic cardiovascular
disease (established CVD or FH):
Allergies:
Physician NPI #: ________________________________
© 2019 Amgen Inc. All rights reserved.
USA-145-80884
Physician NPI #: ________________________________
INDICATIONS AND IMPORTANT SAFETY INFORMATION
Prevention of Cardiovascular Events: In adults with established cardiovascular disease, Repatha
®
is indicated to reduce the risk
of myocardial infarction, stroke, and coronary revascularization.
Primary Hyperlipidemia (including Heterozygous Familial Hypercholesterolemia): Repatha
®
is indicated as an adjunct to diet,
alone or in combination with other lipid-lowering therapies (e.g., statins, ezetimibe), for the treatment of adults with primary
hyperlipidemia to reduce low-density lipoprotein cholesterol (LDL-C).
Homozygous Familial Hypercholesterolemia: Repatha
®
is indicated as an adjunct to diet and other LDL-lowering therapies
(e.g., statins, ezetimibe, LDL apheresis) for the treatment of patients with homozygous familial hypercholesterolemia (HoFH) who
require additional lowering of LDL-C.
The safety and effectiveness of Repatha
®
have not been established in pediatric patients with HoFH who are younger than
13 years old or in pediatric patients with primary hyperlipidemia or HeFH.
Contraindication: Repatha
®
is contraindicated in patients with a history of a serious hypersensitivity reaction to Repatha
®
. Serious
hypersensitivity reactions including angioedema have occurred in patients treated with Repatha
®
.
Allergic Reactions: Hypersensitivity reactions (e.g. angioedema, rash, urticaria) have been reported in patients treated with Repatha
®
,
including some that led to discontinuation of therapy. If signs or symptoms of serious allergic reactions occur, discontinue
treatment with Repatha
®
, treat according to the standard of care, and monitor until signs and symptoms resolve.
Adverse Reactions in Primary Hyperlipidemia (including HeFH): The most common adverse reactions (>5% of patients treated
with Repatha
®
and occurring more frequently than placebo) were: nasopharyngitis, upper respiratory tract infection, influenza, back
pain, and injection site reactions.
From a pool of the 52-week trial and seven 12-week trials: Local injection site reactions occurred in 3.2% and 3.0% of Repatha
®
-
treated and placebo-treated patients, respectively. The most common injection site reactions were erythema, pain, and bruising.
Allergic reactions occurred in 5.1% and 4.7% of Repatha
®
-treated and placebo-treated patients, respectively. The most common
allergic reactions were rash (1.0% versus 0.5% for Repatha
®
and placebo, respectively), eczema (0.4% versus 0.2%), erythema
(0.4% versus 0.2%), and urticaria (0.4% versus 0.1%).
Adverse Reactions in the Cardiovascular Outcomes Trial: The most common adverse reactions (>5% of patients treated with
Repatha
®
and occurring more frequently than placebo) were: diabetes mellitus (8.8% Repatha
®
, 8.2% placebo), nasopharyngitis
(7.8% Repatha
®
, 7.4% placebo), and upper respiratory tract infection (5.1% Repatha
®
, 4.8% placebo).
Among the 16,676 patients without diabetes mellitus at baseline, the incidence of new-onset diabetes mellitus during the trial was
8.1% in patients assigned to Repatha
®
compared with 7.7% in those assigned to placebo.
Adverse Reactions in Homozygous Familial Hypercholesterolemia (HoFH): The adverse reactions that occurred in at least two
patients treated with Repatha
®
and more frequently than placebo were: upper respiratory tract infection, influenza, gastroenteritis,
and nasopharyngitis.
Immunogenicity: Repatha
®
is a human monoclonal antibody. As with all therapeutic proteins, there is potential for immunogenicity
with Repatha
®
.
Please click here for full Prescribing Information.
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Specialty Pharmacy Intake Form

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Completed 15 September 2020

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