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11162 Runner Blvd, Lenexa, KS 66219 Fax Form To: 18005713995 Phone: 8003600520 ext. 1036993 Email Form To: Customer.ServiceFax@CVSHealth.comPrescription Order / Nursing Order PATIENT INFORMATION Needs

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How to fill out and ultomiris prescription and

01

Obtain a prescription from a licensed healthcare provider.

02

Take the prescription to a pharmacy that carries Ultomiris.

03

Provide your insurance information to the pharmacy to determine coverage.

04

Pick up the medication and follow the instructions provided by the pharmacist or healthcare provider.

Who needs and ultomiris prescription and?

01

Patients diagnosed with Paroxysmal Nocturnal Hemoglobinuria (PNH) may need an Ultomiris prescription.

02

Patients who are prescribed Ultomiris may have symptoms such as hemolysis, anemia, and fatigue.

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What is an Ultomiris prescription?

Ultomiris is a prescription medication used to treat certain blood disorders.

Who is required to file an Ultomiris prescription?

Healthcare providers are required to file an Ultomiris prescription for their patients.

How to fill out an Ultomiris prescription?

To fill out an Ultomiris prescription, the healthcare provider must include the patient's information, dosage instructions, and any other relevant details.

What is the purpose of an Ultomiris prescription?

The purpose of an Ultomiris prescription is to provide patients with the necessary medication to manage their condition.

What information must be reported on an Ultomiris prescription?

The Ultomiris prescription must include the patient's name, date of birth, dosage instructions, and prescribing healthcare provider's information.

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