PATIENT INFORMATION PRESCRIPTION BENEFITS PROVIDER Provider: ________________________________ Phone: ( ____ ) - ____ - _____ ID #: __________________ Group #: __________ Rx BIN: ___________ Rx PCN: _______________ PRESCRIBER INFORMATION Prescriber Name: ______________________________________________________ _ Office Phone: _____________________ Fax: _____________________ ___________ Clinic/Hospital Affiliation: _________________________________________________ Address ________________________City:_______ ______ _ State:____ Zip:_______ _ License#:________________ NPI#:__________________Contact:____________ _____ DIAGNOSIS Patient Name: ___________________________________________________________________________________________________ Date of Birth: ____ /____ / ____ Male Female ( Childbearing) SSN: ____ -____ - ____ Address: _____________________________________________ City: _______________________ State: ________ Zip: __________ Phone: ( ____ ) - ____ - ________ Alternate Phone: ( ____ ) - ____ - ________ email: _________________________________________ Preferred method of contact: Phone Email Text Other: __________________ Height: ________ in Weight: ________ lb Allergies: ____________________________ Current Medications: _____________________________________________________________________________________________ Medication Strength / Directions for use Refills By signing below, I authorize Metro Drugs Pharmacy, LLC and its representatives to act as an agent to initiate and execute the insurance prior authorization process. I also certify that the above therapy is medically necessary and that the information above is accurate to the best of my knowledge. Prescriber’s signature: _________________________________ MD DO PA CRNP Date: ____ /____ / ____ NO STAMPS In order for a brand name product to be dispensed, the prescriber must handwrite “Brand Necessary” or “Brand Medically Necessary on the prescription. SHIPPING INFORMATION Ship to: Patient Physician/Clinic Date Shipment Needed By: ____ /____ / ____ Crohn’s /UC Enrollment Form Fax Referrals To: ( 718 ) 795-1639 CLINICAL CONSIDERATIONS Crohn’s Severity: Moderate Severe Enterocutaneous/Recto Vaginal Fistulas Has Patient been diagnosed with Heart Failure ? Has patient been diagnosed with Lymphoma? Does patient have serious/active infection? Has TB test been performed? Yes No Is patient at risk for Hepatitis B infection? If Yes, has Hepatitis B been ruled out or treatment initiated? Does patient have a Latex allergy? Patient weight:________________ kg/lbs Are there any contradications to previous treatments? If Yes, Results: _____________________ K50.90 K50._______ Crohn’s Disease: K50.00 K50.10 K50.80 Other: ______________________ Ulcerative Colitis: K51.90 K51._____ CONFIDENTIALITY NOTICE: This fax is for use only by the person named above. It is private. It may be subject to HIPAA Privacy and security rules. You may not use, copy or share this fax without permission. Please call us at (877) 577-1447 if you received this fax by mistake. Do not destroy this fax until you have spoken with us. We may ask you to destroy or return the fax to us. Thank you for your cooperation. Metro Drugs LLC. (Please fax copy of front and back of card) 100mg/0.5mL SmartJect Autoinjector 100mg/0.5mL Prefilled Syringe Inject 100mg (0.5ml) subcutaneously once a month STELARA ® SIMPONI ® CIMZIA ® ENTYVIO ® HUMIRA ® REMICADE ® SIMPONI ARIA ® 130mg/26mL IV vial 90mg Prefilled Syringe Induction Dose: Infuse 260mg Infuse 520mg Inject 90mg every 8 weeks subcutaneously Maintenance Dose: Quantity Infuse 390 mg 2mg/kg IV at weeks 0 and 4, then every 8 weeks Other : _______________________________________________________________ 100mg vial _____________ mg/kg Maintenance Dose: IV at 5mg/kg (Dose = ___________ mg) every 8 weeks Other: ________________________________________________________ Crohn’s Starter Package 40mg Self Injectable Pen 40mg Prefilled Syringe Induction Dose: IV at 5mg/kg (Dose = ___________ mg) at 0.2, and 6 weeks Maintenance Dose: Inject SC 40mg (one pen) every other week. Maintenance Dose: Inject SC 40mg (one syringe) every other week. Induction Dose: Inject subcutaneously 160mg (4 pens) on day 1, then 80mg (2 pens) on day 15, then maintenance dosing. Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 300mg in a single dose vial in individual carton Recommended dosage in UC and CD: 300mg infused IV over 30 minutes at 0.2 and 6 weeks, then every 8 weeks thereafter. 200mg/1mL Prefilled Syringe 200mg vial Cimzia Starter Kit Induction Dose: Inject SC 400mg (2 Injections) on day 1, and at weeks 2 and 4. Maintenance Dose: Inject subcutaneously 400mg (2 injections) every 4 weeks. 1 kit (6 prefilled syringes) 1 Package _______ # of 100mg vials Other : _____ ___ _________ Metro Drugs Pharmacy 134-02 Jamaica Avenue Queens, NY 11418 Phone : 718-206-4653