MRNDOBPhone 18008091265 Fax 18668728920VyeptiTMeptinezumabjjmrNOTEWe mayrequire a detailed Letter of Medical Necessity or clinical supporting documentation depending on diagnosis to be able tov ID: 883255
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1 MRN: DOB: _ Phone: 1 - 800 -
MRN: DOB: _ Phone: 1 - 800 - 809 - 1265 Fax: 1 - 866 - 872 - 8920 Standard Plan of Treatment for Vyepti TM ( eptinezumab - jjmr ) NOTE : We may require a detailed Letter of Medical Necessity or clinical supporting documentation (depending on diagnosis), to be able to verify eligibility and payment for this treatment through Medicare and/or other insurance plans. 1. Patient Name: Height (inche s): Weight (lbs): 2. Allergies: 3. Diagnosis : 4. Order: Vyepti 100mg intravenous infusion every 3 months Vyepti 300mg intravenous infusion every 3 months Administer intravenously over 30 minutes with a 0.2 or 0.22 micron filter After completion of infusion, flush line with 20ml of 0.9% Sodium Chloride Injection, USP Special : If adverse drug reaction occurs, utilize the ADVERSE DRUG REACTION GUIDELINES 5. Physician’s Signature : / Date: (Dispense as written) (Substitution permitted) No Stamp Signatures Printed Physician’s Name with Credentials: NPI: 6. Fax updated supporting clinical MD notes with each order renewal or change in orders Infusion order forms and Adverse Drug Reaction Guidelines are available at www.palmettoinfusion.com CO NFIDENTIAL Property of Palmetto Infusion Services / CONFIDENTIAL Property of Palmetto Infusion Services / CONFIDENTIAL Property of Palmetto Infusion Services / CONFIDENTIAL Prop erty of Palmetto Infusion Services
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MRN: DOB: _ Phone: 1 - 800 - 809 - 1265 Fax: 1 - 866 - 872 - 8920 Guidelines for Prescribing Vyepti TM ( eptinezumab - jjmr ) (Required documentation with all initial referrals) Patient Name: Referral Date: Include signed and completed Plan of Treatment . (MD must complete sections 1 - 6) (Infusion order forms & Standard Adverse Reactions orders are available at www.palmettoinfusion.com under Agency/MD tab) Include patient demographic information and insurance information. (Copy of insurance cards if available) Supporting clinical MD notes to include any past tried and/or failed therapies, intolerance, outcomes or contraindications to conventional therapy. Include any lab results and/or tests to support diagnosis. Other as requested: Palmetto Infusion Services will complete insurance verification and submit all required clinical documentation to the patient’s insurance company for eligibility. Our office will notify you if any further information is required. We will review financial responsibility with the patient and refer them to any available Copay assistance as required. Thank you for the referral. Please fax all information to 1 - 866 - 872 - 8920 or call 1 - 800 - 809 - 1265 for assistance. CO NFIDENTIAL Property of Palmetto Infusion Services / CONFIDENTIAL Property of Palmetto Infusion Services / CONFIDENTIAL Property of Palmetto Infusion Services / CONFIDENTIAL Pr operty of Palmetto Infusion Service