pharmacy order form

Description for a Remicade order form or contact Specialty Pharmacy at the phone number listed above. for a Humira order form or contact Specialty Pharmacy at the phone number listed above REMICADE Infliximab - J1745 Please see www. CIGNA Specialty Pharmacy Services Plaque Psoriasis Fax Order Form Please deliver by Requests received after 4 p.m. CT will begin processing the following business day. Yes LOCAL HOME HEALTH AGENCY PRESCRIPTION INFORMATION ENBREL Etanercept - J1438 Please see www. for a Enbrel order form or contact Specialty Pharmacy at the phone number listed above HUMIRA Adalimumab J0135 Please see www. Fax 1. 800. 351. 3616 Phone 1. 800. 351. 3606 PHYSICIAN INFORMATION Referral Source Code 652 Order PATIENT INFORMATION Please Print PATIENT NAME DATE OF BIRTH NAME HEALTH CARE ID SEX DEA M HOME PHONE WORK PHONE ADDRESS Street NPI F ALT PHONE City Street/Suite TELEPHONE State Zip Code SHIP MEDICATIONS TO FAX Physician s Office Member s Home Please provide all available patient phone numbers in Patient Information section at left. This is REQUIRED for scheduling delivery. ALLERGIES HOME HEALTH SERVICES REQUIRED No If no allergies are specified for new customers this indicates no known allergies and for existing customers this indicates no change from information provided to CIGNA Specialty Pharmacy previously. STELARA 45mg/0. 5ml Prefilled Syringe ustekinumab J3590 Recommended dose for people weighing 100 kg 220 lbs is 45mg DIRECTIONS QTY Starter Dose Dispense starter dose 1 and 2 Inject 45mg SC initially and 4 weeks later Other QTY refills Other Patient s weight lb kg Maintenance Dose Inject 45mg SC every 12 weeks 1 dose refills PHYSICIAN S PRINTED NAME DATE PHYSICIAN S SIGNATURE Physician s signature indicates accuracy and completeness of prescription information CIGNA Preferred Status It is the decision of the prescribing physician in the exercise of his/her independent clinical judgment to determine which medication to prescribe. Coverage is not limited to the preferred drug. CIGNA HealthCare may receive payments from manufacturers whose medications are included on the Preferred Specialty Injectable Drug List. These payments may or may not be shared with the member s benefit plan dependent on the contractual arrangement between the plan and CIGNA. Depending upon plan design market conditions the extent to which manufacturers payments are shared with the member s benefit plan and other factors as of the date of service the preferred medication may or may not represent the lowest cost medication within the therapeutic class for the member and/or the benefit plan* CIGNA Tel-Drug and the Tree of Life logo are registered service marks and CIGNA Specialty Pharmacy is a service mark of CIGNA Intellectual Property Inc* licensed for use by CIGNA Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries including Tel-Drug Inc* and Tel-Drug of Pennsylvania L*L*C.
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pharmacy order form
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