Chester Clinic

 

Perforomist.aspnprograms.com

(formoterol fumarate) Inhalation Solution ENROLLMENT FORM
Customer Service: (844) 730-8818 PLEASE FAX COMPLETED FORM TO: (844) 730-8819By enrolling your patient in the Mylan Specialty L.P. BreathAssist Program, your patient will receive: (1) benefits investigation and reimbursement support, (2) pharmacy access support, and (3) refill and late fill reminder calls (only available for patients who choose to have their prescription filled by a BreathAssist network specialty pharmacy). BreathAssist representatives will contact patients by telephone after an initial benefits investigation has been completed to explain the BreathAssist Program and the patient's plan coverage for PERFOROMIST, and to offer patients the opportunity to have BreathAssist representatives transmit their prescription to a pharmacy of their choice or to a BreathAssist network specialty pharmacy. Patients who elect to use a BreathAssist network specialty pharmacy will also be given the opportunity to participate in the refill and late *Indicates required field fill reminder call component of the program.
*Prescriber Name (Last, First): *Patient Name (Last, First): Drug: PERFOROMIST (formoterol fumarate) Inhalation solution 20mcg/2ml vial
(NDC: 49502-605-61)
*Prescriber Phone #: *Quantity (60 vials per carton): *Directions: one 20mcg/2ml unit-dose vial administered twice daily (morning and evening) via nebulizer: *Does the patient require a nebulizer? Office Contact Name: If Yes, what type: £tabletop £portable IF YES. please fax a signed prescription to (844) 730-8819, including patient's complete
demographics and diagnosis code.
*Patient Name (Last, First): Would you like to prescribe nebulized Albuterol for this patient? One free 30-vial carton of nebulized Albuterol every 90 days is available for patients who have been prescribed PERFOROMIST within the last 30 days. £Yes £No Drug: Albuterol Sulfate Inhalation Solution 0.083% 2.5mg/3ml (NDC: 00378-8270-55)
*Quantity (30 vials per carton): 1 Please check the box below to indicate whether you wish to have the patient's prescription filled by a BreathAssist Network Pharmacy or by the patient's preferred pharmacy: PATIENT DIAGNOSIS (Required information)
£ Fill at Network Specialty Pharmacy £ Fill at Pharmacy Indicated Below If patient prefers a specific pharmacy, complete ALL the fields. *Please list any known allergies to medication or other substances: *Deliver to: £ Patient's Home £ Physician's Office PHARMACY INSURANCE INFORMATION
PROVIDER ATTESTATION
By my signature, I verify that the information being provided in this form is, to the best of my knowledge,
Please complete all fields below with the patient's insurance information, or include
complete and accurate. I have sought, received, and documented from the patient identified on this form: a copy of the front AND back of the prescription benefit card.
a) authorization to share his/her personal health information with program administrator Armada Specialty Pharmacy Network LLC (ASPN), for the purposes of this BreathAssist Program, and b) permission to enroll him/her in the BreathAssist Program services described above. I also verify that I have informed the patient that the BreathAssist Program and its related services are not intended to serve as medical or clinical advice or care and cannot take the place of conversations with his or her treating physician. Finally, I understand that Mylan Specialty L.P. or its program administrator ASPN reserves the right at any time and for any reason, without notice, to modify this enrollment form or to modify or discontinue any services or assistance provided through this Program.
Please send me status updates via email. You may opt-in to receive e-mails from BreathAssist
regarding the status of your patient's prescription. By agreeing to receive e-mails from BreathAssist, you acknowledge that BreathAssist will send standard e-mails to you via the Internet. Therefore, there MEDICARE PART B INFORMATION
is potential for these unencrypted emails to be intercepted by unauthorized third parties. If you share your email account or computer with others, those parties may be able to access your confidential information. You should notify BreathAssist immediately if you wish to cease receiving e-mails or if your *Does the patient have Medicare Part B: £Yes £No e-mail address changes. You should not use e-mails for emergencies.
Medicare Part B #: *Prescriber's Signature Supplemental insurance: (Dispense As Written) *Date of Signature Important Safety Information for PERFOROMIST
WARNING: ASTHMA-RELATED DEATH
Long-acting beta -adrenergic agonists (LABA) increase the risk of asthma-related death. Data from a large placebo-controlled US study that compared the safety of another long-acting beta -adrenergic agonist (salmeterol) or placebo added to usual asthma therapy showed an increase in asthma-related deaths in patients receiving salmeterol. This finding with salmeterol is considered a class effect of LABA, including formoterol, the active ingredient in PERFOROMIST® Inhalation Solution.
The safety and efficacy of PERFOROMIST in patients with asthma have not been established. All LABA, including PERFOROMIST, are contraindicated in patients with asthma without use of a long-term asthma control medication.
Please see additional Important Safety Information for Perforomist on reverse side and accompanying full Prescribing Information, including
Boxed Warning and Medication Guide. Please see Important Safety Information for Albuterol Inhalation Solution on reverse side.

(formoterol fumarate) Inhalation Solution ENROLLMENT FORM
Customer Service: (844) 730-8818 PLEASE FAX COMPLETED FORM TO: (844) 730-8819By enrolling your patient in the BreathAssist Program, your patient will receive: (1) benefits investigation and reimbursement support, (2) pharmacy access support, and (3) refill and late fill reminder calls (only available for patients who choose to have their prescription filled by a BreathAssist network specialty pharmacy). BreathAssist representatives will contact patients by telephone after an initial benefits investigation has been completed to explain the BreathAssist program, the patient's plan coverage for PERFOROMIST, and offer patients the opportunity to have BreathAssist representatives transmit their prescription to a pharmacy of their choice or a BreathAssist network specialty pharmacy. Patients who elect to use a BreathAssist network specialty pharmacy will also be given the opportunity to participate in the refill and late fill reminder call component of the program.
Indication
PERFOROMIST® (formoterol fumarate) Inhalation Solution is indicated for the long-term, twice-daily (morning and evening) administration in the maintenance
treatment of bronchoconstriction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema.
Important Limitations for Use:
•
It is not indicated to treat acute deteriorations of COPD.
It is not indicated to treat asthma. The safety and effectiveness of PERFOROMIST Inhalation Solution in asthma has not been established.
Important Safety Information
PERFOROMIST Inhalation Solution like other LABAs is contraindicated in patients with asthma without use of a long-term asthma control medication.
PERFOROMIST Inhalation Solution should not be initiated in patients with acutely deteriorating COPD, which may be a life-threatening condition. PERFOROMIST Inhalation Solution should not be used for the relief of acute symptoms, i.e., as rescue therapy for the treatment of acute episodes of bronchospasm.
As with other inhaled beta -agonists, PERFOROMIST Inhalation Solution can produce paradoxical bronchospasm that may be life-threatening. If paradoxical bronchospasm occurs, PERFOROMIST Inhalation Solution should be discontinued immediately and alternative therapy instituted.
PERFOROMIST Inhalation Solution should not be used more often, at higher doses than recommended, or in conjunction with other inhaled, long-acting beta -2 agonists, as an overdose may result. Clinically significant cardiovascular effects and fatalities have been reported in association with excessive use of inhaled sympathomimetic drugs.
PERFOROMIST Inhalation Solution should be used with caution in patients with cardiovascular disorders, especially coronary insufficiency, cardiac arrhythmias, and hypertension; in patients with convulsive disorders or thyrotoxicosis; and in patients who are unusually responsive to sympathomimetic amines.
PERFOROMIST Inhalation Solution, like other beta -agonists, can produce a clinically significant cardiovascular effect in some patients as measured by increases in pulse rate, systolic and/or diastolic blood pressure, and/or symptoms.
PERFOROMIST Inhalation Solution, like other sympathomimetic amines, should be used with caution. Doses of the related beta -agonist albuterol, when administered intravenously, have been reported to aggravate preexisting diabetes mellitus and ketoacidosis.
Beta agonist medications may produce significant hypokalemia in some patients, which has the potential to produce adverse cardiovascular effects. The decrease in serum potassium is usually transient, not requiring supplementation.
Immediate hypersensitivity reactions may occur after administration of PERFOROMIST Inhalation Solution, as demonstrated by cases of anaphylactic reactions, urticaria, angioedema, rash, and bronchospasm.
PERFOROMIST Inhalation Solution, as with other beta -agonists, should be used with extreme caution in patients being treated with monoamine oxidase inhibitors, tricyclic antidepressants, or drugs known to prolong the QTc interval because the action of adrenergic agonists on the cardiovascular system may be potentiated by these agents.
Beta-blockers and formoterol fumarate may inhibit the effect of each other when administered concurrently. Therefore, patients with COPD should not normally be treated with beta-blockers except under certain circumstances e.g., as prophylaxis after myocardial infarction, there may be no acceptable alternatives to the use of beta-blockers in patients with COPD.
Concomitant treatment with Xanthine derivatives, steroids, or diuretics may potentiate any hypokalemic effect of adrenergic agonists. The EKG changes and/or hypokalemia that may result from the administration of non-potassium sparing diuretics (such as loop or thiazide diuretics) can be acutely worsened by beta- agonists, so caution is advised in the coadministration.
The most common adverse reactions (≥ 2% and more common than placebo) with PERFOROMIST are diarrhea, nausea, nasopharyngitis, dry mouth, vomiting, dizziness, and insomnia.
You are encouraged to report negative side effects of prescription drugs to the FDA.
Visit www.fda.gov/medwatch or call 1-800-FDA-1088.
Please see accompanying full Prescribing Information, including Boxed Warning and Medication Guide. Important Safety Information for Albuterol Sulfate Nebulizer Solution
Albuterol Sulfate Inhalation Solution 0.083 %*
(*Potency expressed as albuterol, equivalent to 3 mg albuterol sulfate) Indications And Usage
Albuterol sulfate inhalation solution is indicated for the relief of acute attacks of bronchospasm.
Important Safety Information
FOR INHALATION USE ONLY–NOT FOR INJECTION The Mylan logo is a registered trademark of Mylan Inc. PERFOROMIST® is a registered trademark of Mylan Specialty L.P. 2015 Mylan Specialty L.P. All rights reserved. 03/15 PER-2015-0180

(formoterol fumarate) Inhalation Solution ENROLLMENT FORM
Customer Service: (844) 730-8818 PLEASE FAX COMPLETED FORM TO: (844) 730-8819By enrolling your patient in the BreathAssist Program, your patient will receive: (1) benefits investigation and reimbursement support, (2) pharmacy access support, and (3) refill and late fill reminder calls (only available for patients who choose to have their prescription filled by a BreathAssist network specialty pharmacy). BreathAssist representatives will contact patients by telephone after an initial benefits investigation has been completed to explain the BreathAssist program, the patient's plan coverage for PERFOROMIST, and offer patients the opportunity to have BreathAssist representatives transmit their prescription to a pharmacy of their choice or a BreathAssist network specialty pharmacy. Patients who elect to use a BreathAssist network specialty pharmacy will also be given the opportunity to participate in the refill and late fill reminder call component of the program.
Contraindications – Albuterol sulfate inhalation solution is contraindicated in patients with a history of hypersensitivity to any of its components.
Warnings – As with other inhaled beta-adrenergic agonists, albuterol sulfate inhalation solution can produce paradoxical bronchospasm, which can be life
threatening. If it occurs, the preparation should be discontinued immediately and alternative therapy instituted.
Fatalities have been reported in association with excessive use of inhaled sympathomimetic drugs and with the home use of nebulizers. It is, therefore, essential that the physician instruct the patient in the need for further evaluation, if his/her symptoms become worse. In individual patients, any beta2-adrenergic agonist, including albuterol solution for inhalation, may have a clinically significant cardiac effect. Immediate hypersensitivity reactions may occur after administration of albuterol as demonstrated by rare cases of urticaria, angioedema, rash, bronchospasm, and oropharyngeal edema.
Precautions – Albuterol, as with all sympathomimetic amines, should be used with caution in patients with cardiovascular disorders, especially coronary
insufficiency, cardiac arrhythmias and hypertension, in patients with convulsive disorders, hyperthyroidism or diabetes mellitus and in patients who are unusually responsive to sympathomimetic amines.
Large doses of intravenous albuterol have been reported to aggravate pre-existing diabetes mellitus and ketoacidosis. As with other beta-agonists, inhaled and intravenous albuterol may produce a significant hypokalemia in some patients, possibly through intracellular shunting, which has the potential to produce adverse cardiovascular effects. The decrease is usually transient, not requiring supplementation.
Drug interactions – Other sympathomimetic aerosol bronchodilators or epinephrine should not be used concomitantly with albuterol. Albuterol should be
administered with extreme caution to patients being treated with monoamine oxidase inhibitors or tricyclic antidepressants. Beta-receptor blocking agents and albuterol inhibit the effect of each other.
If a previously effective dosage regimen fails to provide the usual relief, medical advice reevaluation of treatment should be sought immediately.
Adverse reactions – Clinical trials with albuterol sulfate inhalation solution in 135 patients showed the following adverse reactions which were considered
probably or possibly drug related: tremors (20%), dizziness (7%), nervousness (4%), headache (3%), insomnia (1%), nausea (4%), dyspepsia (1%), nasal congestion (1%), bronchospasm (8%), cough (4%), bronchitis (4%), wheezing (1%), tachycardia (1%), and hypertension (1%).
To report SUSPECTED ADVERSE REACTIONS, contact Mylan Pharmaceuticals Inc. at 1-877-446-3679 (1-877-4-INFO-RX) or FDA at 1-800-FDA-1088 or
www.fda.gov/medwatchPlease see accompanying full Prescribing Information.
The Mylan logo is a registered trademark of Mylan Inc. PERFOROMIST® is a registered trademark of Mylan Specialty L.P. 2015 Mylan Specialty L.P. All rights reserved. 03/15 PER-2015-0180

Source: https://perforomist.aspnprograms.com/siteforms/Perforomist_Form.pdf