Fax# 855 -447 -6637 Ph#: 855-650-5009 Dermatology Prescription Faxable

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MEDICATION DIRECTION QTY. REFS.

Cosentyx ®Plaque Psoriasis: Induction Dose: Inject 300mg SQ at weeks 0,1,2,3, and 4

Plaque Psoriasis: Maintenance Dose: Inject 300mg SQ every 4 weeks

Psoriatic Arthritis: Induction Dose:

Enbrel ®: Inject 50mg SQ twice a week (3-4 days apa rt) for 3 months

Other:

Humira ® Inject 80mg SQ on day 1, then one 40mg on day 8, then 40mg every other week. Psoriasis: Maintenance Dose: Inject 40mg SQ every other week

Psoriatic Arthritis Dose : Inject 40mg SQ every other week

Other:

Simponi ® Psoriasis Arthritis Dose: Inject 50mg (0.5ml) SQ once a month

Stelara ® 45mg/0.5ml Prefilled Syr 90mg/1ml Prefilled Syr

Otelza ® Titration Starter Pack Rx

30 mg Take one tablet twice a day

Psoriatic Arthritis: Maintenance Dose:

50mg/ml Sureclick 50mg/ml Prefilled Syr 25mg/0.5ml Prefilled Syr 25mg Vial

Psoriasis: Induction Dose

Psoriatic Arthritis Dose: Inject 50mg SQ once a week

Psoriasis Starter Package

40mg/0.8ml Pen 40mg/0.8ml Prefilled Syr

Other:

Day 1: 10mg orally in the morning.Day 2: 10mg orally in the morning and 10mg orally in the evening. Day 3: 10mg orally in the morning and 20mg orally in the evening. Day 4: 20mg orally in the morning and 20mg orally in the evening. Day 5: 20mg orally in the morning and 30mg orally in the evening. Day 6: and thereafter 30mg orally twice a day.

100mg/ml

HS Starter Package

40mg Pen

40mg Prefilled Syr

Loading: Inject 100mg SQ week 0 & week 4 Maintenance: Inject 100mg SQ every 8 weeks

Other:

150mg/ml PFS

150mg/ml PEN

Induction Dose: Inject SQ 160mg (4pens) on day 1, then 80mg (two pens) on day 15, then maintenance dosing

Maintenance Dose: Inject SQ 40mg (1 syringe) every other week

Sharps Package: (Sterile sponges, alcohol swabs, sharps container)

210mg/1.5ml Inject 210mg SQ at weeks 0,1,2, then every 2 weeks thereafter

For patients weighing <100kg (220lbs): Inject 45 mg SQ initially and 4 weeks later followed by 45mg every 12 weeksFor patients weighing >100kg (220lbs): Inject 90 mg SQ initially and 4 weeks later followed by 90mg every 12 weeksInject SQ every 12 weeks

Inject 150mg SQ at weeks 0,1,2,3 and 4 every 4 weeks

Inject 150mg SQ every 4 weeks

Psoriasis: Maintenance Dose: Inject 50mg SQ once a week

Prescriber Signature:

Today’s Date: ___________________ Needed by: ___________________ Name: ________________________________ ______________________ _Ph___o_ne:__________ ________

Home Phone: Alt. Phone: SS#: Date of Birth:

Weight: Gender: Height: BSA m2

Prescriber: (Provide as much information as possible)

NPI#: Group/Hospital: Prescriber’s Name:

Position: Insurance Information (Please copy and attach the front and back of the Insurance Card): Primary Insurance Name: ID# BIN# Group# PCN# Phone:

No Insurance Patient will pay out of pocket Enroll in Manufacturer’s Patient Assistance Program Medication Delivery to (Choose Only On e): Patient Address First Fill Physician’s Of�ice, Re�ill to Patient Address Patient will pick up at Pharmacy

L40.54 Psoriatic Arthritis L40.59 Other Psoriatic Arthropathy L40.8 Other Psoriasis L40.9 Psoriasis, Unspeci�ied L73.2 Hidradenitis Suppurati v a O ther: Psoriasis Type: Plaque Other Comorbidity: Da t e o f D i a g nosis: OR Years with Disease: Disease State Severity: Severe Moderate

Injection Training & Educational Needs: Specialty Pharmacy Injection Training Requested Manufacturer’s Patient Assistance Program Enrollment Requested OR (Please choose only one) Physician’s Of�ice already trained Patient Patient is already independently

Prior (Failed) Medications (Reason for D/C):

DEA:

Psoriasis: Induction Dose: 1Package

1Package

Maintenance Dose: Inject SQ 40mg (1 pen) every other week

Humira HS ®

Siliq ®

Tremfya ®

Patient Allergies / Allergic Reactions:

Diagnosis (ICD 10 code): L40.0 Psoriasis Vulgaris L40.1 Generalized Pustular Psoriasis L40.4 Guttate Psoriasis L40.50 Arthropatic Psoriasis, Unspecified

City, State, Zip:

Patient Name: Patient Demographic: Provide the following or attach demographic sheet

Address:

50mg/0.5ml Smartject Auto Inj. 50mg/0.5ml Prefilled Syr

Phone:Alt. Contact Name:Phone: City, State, Zip: Address: Specialty:

DOSE/ STRENGTH

80mg/ml Loading: Inject 160mg SQ once, followed by 80mg weeks 2,4,6,8,10, and 12 and then 80mg every 4 weeks Maintenance: Inject 80mg SQ every 4 weeks

Taltz ®

Cimzia ® 200mg/ml Prefilled Syr 200mg Vial

Inject 400mg (2 injections of 200mg each) SQ every other weekFor patients weighing 90kg or less:

Maintenance: Inject 200mg SQ every other weekLoading: Inject 400mg SQ at weeks 0, 2, and 4, then 200mg SQ every other week