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Oncology Hematologic Cancer (drugs A-J) (Bosulif ® , (Farydak ® , Gleevec ® , IDHIFA ® , Imbruvica ® , and Jakafi ® ) Patient Information Prescriber + Shipping Information Patient name: ________________________ DOB: _____________ Sex: Female Male SSN: ______________________________ Language: ____________ Wt: _____ kg lbs Ht: _____cm in Address: _______________________________________________ Apt/Suite: _____ City: ________________ State: _____ Zip: ______ Phone: ___________________ Alternate: ____________________ Caregiver name: ____________________ Relation: _____________ Local pharmacy: _____________________ Phone: _____________ Insurance plan: _________________ Plan ID: ________________ Please fax a copy of front and back of the insurance card(s). Prescriber name: _______________________________________ NPI: _________________________________________________ Address: ______________________________________________ Apt/Suite: ______ City: ____________ State: _______ Zip: ______ Contact: ______________________________________________ Phone: _____________________ Alternate: _________________ Fax: _________________________________________________ Email: ________________________________________________ If shipping to prescriber: First Fill Always Never Clinical Information (Please fax all pertinent clinical and lab information) Diagnosis (C00-D49): _____________________________________________________________ Diagnosis date: ________________ Patient Type (if applicable): Adult female NOT of reproductive potential Adult female of reproductive potential Adult male Date: _____________________ Child female NOT of reproductive potential Child female of reproductive potential Child male Authorization: _______________ Mutations: c-Kit Del 5q Del 17p FLT3 IDH2 PDGFR Ph+ Other Mutation ______________________ Lymph Node size: _____ cm Absolute Lymphocyte count: _______/L TLS Risk: Low Moderate High Date:_________________ Reason for Discontinuation of Therapy Approximate Start Date Approximate End Date Prior Therapy Yes No ___________________________ ___________________________ ___________________________ ______________________________________ ______________________________________ ______________________________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ Comorbidities:__________________________________________________________________________________________________ ConcomitantMedications: _________________________________________________________________________________________ Allergies: NKDA Other: _____________________________________________________________________________________ Prescription Quantity Refill Bosulif ® (bosutinib) Take 500 mg by mouth once daily with food __________________________________________________________________ 30 x 500 mg tablets _____________________ ______ Farydak ® (panobinostat) Take 20 mg by mouth once daily on days 1, 3, 5, 8, 10 and 12 of a 21-day cycle _________________________________________________________________ 6 x 20 mg capsules _____________________ ______ Dexamethasone Take 20 mg by mouth once daily with food on days 1, 2, 4, 5, 8, 9, 11, and 12 of a 21-day cycle ___________________________________________________________________ 8 x 20 mg capsules _____________________ ______ Aspirin Take 81 mg by mouth once daily ___________________________________________________________________ 28 x 81 mg tablets _____________________ ______ Gleevec ® (imatinib) Take 400 mg by mouth once daily with a meal and full glass of water Take 600 mg by mouth once daily with a meal and full glass of water Take _______ mg (340 mg/m 2 /day x _______ m 2 ) by mouth once daily with a meal and full glass of water _________________________________________________________________ 30 x 400 mg tablets 30 x 400 mg tablets 60 x 100 mg tablets _____________________ ______ Imbruvica ® (ibrutinib) Take 420 mg by mouth once daily with a full glass of water Take 560 mg by mouth once daily with a full glass of water _________________________________________________________________ 90 x 140 mg capsules 120 x 140 mg capsules _____________________ ______ Jakafi ® (ruxolitinib) Take _______ mg by mouth once daily Take _______ mg by mouth twice daily 30 x ____ mg tablets 60 x ____ mg tablets ______ § Ninlaro ® , Pomalyst ® , Revlimid ® , Rydapt ® , Sprycel ® , Synribo ® , Tasigna ® , Thalomid ® , Venclexta™, Zolinza ® , and Zydelig ® are listed alphabetically on respective enrollment forms§ Per state-specific law, prescriptions will be dispensed as generic, if applicable, unless notated otherwise: __________________________________________ Prescriber’s Signature:_____________________________________________________________________________________ Date: ______________ I authorize Diplomat Pharmacy, Inc. and its representatives to act as an agent to initiate and execute the insurance prior authorization process for this prescription and any future fills of the same prescription for the patient listed above. I understand that I can revoke this designation at any time by providing written notice to Diplomat Pharmacy, Inc. Confidentiality Statement: This message is intended only for the individual or entity to which it is addressed. It may contain information which may be proprietary and confidential. It may also contain privileged, confidential information which is exempt from disclosure under applicable laws, including the Health Insurance Portability and Accountability Act (HIPAA). If you are not the intended recipient, please note that you are strictly prohibited from disseminating or distributing this information (other than to the intended recipient) or copying this information. If you received this communication in error, please notify the sender immediately by calling 810.768.9178 or by emailing [email protected] to obtain instructions as to the proper destruction of the transmitted material. Thank you. 08042017 Copyright © 2017 by Diplomat Pharmacy Inc. All rights reserved. Diplomat is a registered trademark of Diplomat Pharmacy Inc. For patients requiring immune globulin therapy, please fill out the respective form: IVIg or SCIg. Stamp signature not allowed, physician signature required. IDHIFA ® (enasidenib) Take 100 mg by mouth once daily with a full glass of water _________________________________________________________________ 30 x 100 mg tablets _____________________ ______
