IV-Infliximab → SC-Zymfentra® Enrollment Form

Complete this form for patients starting on IV-infliximab induction and transitioning to SC-Zymfentra®

Patient Information

First Name *

Last Name *

Date of Birth *

Gender *

Home Phone

Cell Phone

Email *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Emergency Contact

Emergency Phone

Complete this form for patients starting on IV-infliximab induction and transitioning to SC-Zymfentra®

Insurance Information

Primary Insurance

ID #

Group #

Secondary Insurance

ID #

Group #

Prescription Card ID

Bin #

PCN #

Group #

Complete this form for patients starting on IV-infliximab induction and transitioning to SC-Zymfentra®

Prescriber Information

Prescriber Name

DEA #

NPI #

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone

Fax

Contact Person

Complete this form for patients starting on IV-infliximab induction and transitioning to SC-Zymfentra®

Clinical Information

Patient Weight *

Unitkglbs

Patient Height

Unitcmin

Allergies

TB/PPD TestPositiveNegative

Date Read

Hepatitis B ScreenPositiveNegative

Date Read

Pharmacy to coordinate home health nursing visit and/or nursing training

Length of failed treatment

Reason for discontinuation

Diagnosis

Diagnosis *ICD-10: K50 (Moderately to severely active Crohn's Disease following treatment with an infliximab product administered intravenously)ICD-10: K51 (Moderately to severely active Ulcerative Colitis following treatment with an infliximab product administered intravenously)Other

Other Diagnosis

Requested Therapy Start Date

Prior Medication Failed

Complete this form for patients starting on IV-infliximab induction and transitioning to SC-Zymfentra®

Prescription Information

Dose and Directions(Dose to be calculated based on actual body weight)

Patient Weight *

Unitkglbs

Dose (in mg)

mg/kg3mg/kg5mg/kg10mg/kg

Induction Dose

Infuse __mg IV at weeks 0, 2 and 6

*Pharmacists to round to the nearest 100mg, unless otherwise indicatedGive exact dose (do NOT round)

Quantity

Dispense week 0, 2 and 6

Refill

NONE

Transition to ZYMFENTRA® (SC - infliximab-dyyb) *120mg/mL solution in a single dose pre-filled pen.120mg/mL solution in a pre-filled syringe with needle shield.

Quantity#2 (1 month)#6 (3 months)

# of Refills

Complete this form for patients starting on IV-infliximab induction and transitioning to SC-Zymfentra®

Required for Home Infusion

IV Access & Infusion Method

To be administered PERIPHERALLY, unless otherwise indicatedPORTPICC

To be infused via gravity infusion or per CarePartners RPh discretion, unless otherwise indicated.MD prefers Infusion Pump

Flush Protocol

For IG drug admin days only

0.9% NaCl: 1-10mL IV before/after infusion, or PRN for line patency/SASH.
Heparin 100 units/mL: 5mL IV (central) PRN for final flush.

Pre and Post Medication

Please select only if needed.

To be given 30 minutes prior to infusion. May repeat every 4-6 hours as needed.Diphenhydramine 25mg-50mg by mouth. Adult max: 100mg/dayAcetaminophen 325mg - 650mg by mouth. Adult max: 3000mg/day

Anaphylaxis Protocol

To be given intramuscularly PRN severe allergic reaction. Call 911. May repeat 1x.

Epinephrine 0.3mg (≥30kg / 66lbs)

Diphenhydramine

Please select only if needed

To be given via slow IV push PRN for moderate - severe reaction.25-50mg *For IV Adult Patients Only*

Additional Orders

Complete this form for patients starting on IV-infliximab induction and transitioning to SC-Zymfentra®

Prescriber Signature Required (stamp signature not allowed)

By signing this form and using this pharmacy's services, you are authorizing this pharmacy to serve as your prior authorization designated agent in dealing with prescriptions and medical insurance companies.

SubstitutionsMay Substitute / Product Selection Permitted / Substitution PermissibleDispense As Written / Brand Medically Necessary / Do Not Substitute / No Substitution / May Not Substitute

CA, MA, NC & PR: Interchange is mandated unless Prescriber writes the words "No Substitution"

NY & Iowa providers, please submit electronic prescription.

Prescriber Signature *

Date

The information contained in this facsimile may be confidential and is intended solely for the use of the named recipient(s). Access, copying or re-use of the facsimile or any information contained therein by any other person is not authorized. If you are not the intended recipient, please notify us immediately by faxing back to the originator.

IV-infliximab → SC-Zymfentra® Enrollment Form

Patient Information