Specialty Injection Order Form Rheumatology

Specialty Injection Order Form Rheumatology
(New York prescribers, please submit prescription on an original, official NY State prescription blank or an electronic prescription)
Prescriber's Name:
Pittsburgh
305 Merchant Lane
Pittsburgh, PA 15205
Address:
City
Phone: 844-428-7387
Fax: 844-228-7387
PATIENT INFORMATION
MD / DO / NP / PA
State
Office Contact:
Office Contact:
Phone#
Phone#
NPI:
DEA:
Fax#
Fax#
License:
Send updates to ❏ Fax ❏ E-mail to _________________________
Patient's Name:
Zip
❏ Text to Phone# _________________
SS#
Address:
DOB:
City
Home Phone:
State
Work or Cell:
Allergies:
Emergency Contact:
Sex: M____ F____ Wt:
Patient previously on treatment: Y
Primary Insurance:
N
Zip
Ht:
Diabetic:
Y
N
Date:
Policy#
Insured:
Group
Phone:
BIN#
* Please include current patient medication list with referral *
PCN#
STATEMENT OF MEDICAL NECESSITY
PRIMARY DIAGNOSIS: (ICD-9 CM Code Plus Description) Date of Diagnosis:
❏ 714.0 Rheumatoid Arthritis
❏ 714.30 Arthritis-Rheumatoid, juvenile
❏ 720.0 Ankylosing Spondylitis
Date of onset of symptoms
❏ last CXR date:
TB Status: ❏ Active TB ❏ PPD (-) date:
❏ 720.0 Ankylosing Spondylitis
DNR Status: ❏ Rcíd ❏ N/A
❏ 696.1 Psoriasis, Other
Did patient receive other medical therapies in the last 6 mos.? ❏ No ❏ Yes, Date:
❏ unknown
Other
Medical History: ❏ Diabetes
❏ Current Active Infection
❏ Malignancy
❏ Immunosuppressive Therapy
❏ Heart Failure
❏ CNS Disorder
TREATMENT ARRANGEMENTS
SHIP MEDS
❏ Home ❏ Doctors Office
Is this the first dose?
❏ Yes
❏ No
❏ Pt lives in a region endemic for
Infusion by: ❏ Aureus
Teaching by: ❏ Aureus
❏ Drs. Office ❏ Other
❏ Drs. Office ❏ Other
If no, date first dose given:
®
TOCILIZUMAB (Actemra )
80mg/4ml vials
200mg/10ml vials
400mg/20ml vials
❏ 50ml 0.9% NS bag
❏ 100ml 0.9% NS bag
Sig: __________________________(Above vials will be used to fill dose)
28 days
Refill x ____
❏ NS 0.9% 10ml PFS to flush line before and after infuson
Qty: qs
Refills x ____
ABATACEPT
❏ Immunizations up to date
❏ Other:
❏
bacterial, mycobacterial or
❏ fungal infection
❏ start ASAP
Next dose due:
TOFACITINIB (Xeljanz)
(Orencia® )
Weight
Dose
0 - 60kg = 250mg
❏ Infuse_______mg IV in 100ml NS over 6 0 - 100kg = 500mg
30 minutes on week 0, 2, 4 and
>1 00kg = 750mg
then every 4 weeks.
❏ NS Syringe 10ml IV before and after infusion and as needed.
#QS.
Refill x
28 Day Supply
Dose: 5mg tab by mouth twice daily.
Qty: 60
Refill x __________
FORTEO ®
Inject 20mcg SC, as directed, once daily
Refill x __________
®
❏ 162mg/0.9mL PFS
❏ Dosage: Patients<100kg (220lbs) 162mg (sc) every other week
followed by an increase to every week based on clinical response
❏ Dosage: Patients>100kg (220lbs) 162mg (sc) every week
BELIMUMAB (Benlysta® )
Refills x ____
28 Day Supply
®
CERTOLIZUMAB PEGOL (Cimzia ) PFS
❏ Infuse 10mg/kg diluted in 250ml of NS over
28 Day Supply
❏ 400 mg SQ. on Weeks 0, 2, 4 and then every 4 weeks
Refills x____
one hour at week 0, 2, 4 and then every 4 weeks
❏ NS Syringe 10ml IV before and after infusion
and as needed. #Qs
Refills x_______
ETANERCEPT (Enbrel Sure Click)
®
Other Orders:
Premedications
28 Day Supply
❏ Maintenance dose of 50 mg SQ weekly
❏ Children (2-17 yo) 0.8 mg/kg/wk (up to 50 mg/wk)
once weekly as a single injection or two injections
❏ Other Regimen:
Refills x
ADALIMUMAB (Humira® PEN)
28 Day Supply
❏ Humira Psoriasis Starter Package (Self-Injectable Pen 40mg/0.8ml)
80mg (2 pens) SubQ on day 1, then 40mg (1 pen) on day 8, then 40 mg
(1 pen) on day 22 then on day 36 begin maintenance dosing.
❏ Humira Maintenace (Self-Injectable Pen 40mg/0.8ml)
40mg SubQ injection (1pen) every other week
❏ Other Regimen _______________________________
Refills x ____
*Give 30 minutes before infusion
❏ Diphenhydramine (BenadrylÆ) 25mg Orally x1
❏ Acetaminophen (TylenolÆ) 650 mg Orally x1
❏ Methylprednisolone (Solu-MedrolÆ) _______ mg IV x1
INFLIXIMAB (Remicade® )
56 Day Supply
❏ Infuse 3 mg/kg in 250NS over 2hrs at week 0, 2, 6
Authorized x1 year
Adverse Reactions
And then every 8 weeks
❏ Acetaminophen (TylenolÆ) 650 mg
ORALLY for fever or mild discomfort x1.
❏ Round order up or down to nearest 100mg
❏ Exact dose
❏ Diphenhydramine (BenadrylÆ) 50 mg
ORALLY for mild to moderate allergic
reactions x1
❏ EPIPEN (1:1000) 0.3ml IM for anaphylactic
reactions, contact physician & call 911.
Other Regimen ___________________
❏ NS Syringe 10ml IV before and after infusion and as needed.
#QS.
Refills x ____
Authorized x1 year
By signing this form and utilizing our services, you are authorizing Aureus and its employees to serve as your prior authorization designated agent in dealing with
medical and prescription insurance companies.
Prescriber Signature:
May Substitute
Dispense as Written
Date:
Form # - RH-102714