Imuldosa RxDirect - Enrollment Form | CarePartners Pharmacy

This field is for validation purposes and should be left unchanged.

Patient Information

Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Gender(Required)

Home Phone

Cell Phone

Email Address(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Emergency Contact(Required)

Emergency Phone(Required)

Clinical Information

Patient Weight(Required)

Patient Weight Unit(Required)

lbs

Patient Height(Required)

Patient Height Unit(Required)

Allergies

TB/PPD Test(Required)

Positive

Negative

Date Read

Month

Day

Year

List of Failed Treatments

Primary Diagnosis(Required)

Crohn's Disease (K50)

Ulcerative Colitis (K51)

Plaque Psoriasis (L40)

Psoriatic Arthritis (L40.52)

Prescription Information
Crohn’s Disease/Ulcerative Colitis (Adult)

Prescription Information
Plaque Psoriasis
Adult/Pediatric patients age ≥ 6 and weight ≥ 60kg

Prescription Information
Psoriatic Arthritis
Adult/Pediatric patients age ≥ 6 and weight ≥ 60kg

Date of Last Dose (if known)

Month

Day

Year

Site of Infusion(Required)

Prescriber’s Office/Hospital Outpatient/Infusion Center

MD has provided training & authorizes patient or caregiver to administer SC injections

Other

Please select a loading dose only if required.

IV Loading Dose (Given as a single intravenous infusion)(Required)

≤55kg: 260mg IV at week 0. Then start subcutaneous Maintenance Prescription at Week 8. Dispense 2 vials.

>55kg-85kg: 390mg IV at week 0. Then start subcutaneous Maintenance Prescription at Week 8.Dispense 3 vials.

>85kg: 520mg IV at week 0. Then start subcutaneous Maintenance Prescription at Week 8. Dispense 4 vials.

Other

Subcutaneous Loading Dose(Required)

≤100kg: IMULDOSA® (ustekinumab-srlf) 45mg/0.5mL PFS Administer 1 injection (45mg) SC at Week 0. Then start Maintenance Prescription at Week 4. Quantity: 1 injection, Refills: 0

>100kg: IMULDOSA® (ustekinumab-srlf) 90mg/mL PFS Administer 1 injection (90mg) SC at Week 0. Then start Maintenance Prescription at Week 4. Quantity: 1 injection, Refills: 0

Other

Subcutaneous Loading Dose(Required)

IMULDOSA® (ustekinumab-srlf) 45mg/0.5mL PFS Administer 1 injection (45mg) SC at Week 0. Then start Maintenance Prescription at Week 4. Quantity: 1 injection, Refills: 0

>100kg w/ mod-severe Plaque Psoriasis: IMULDOSA® (ustekinumab-srlf) 90mg/mL PFS Administer 1 injection (90mg) SC at Week 0. Then start Maintenance Prescription at Week 4. Quantity: 1 injection, Refills: 0

Other

Infuse intravenously once over at least 1 hour, Refills: 0
IMULDOSA® (ustekinumab-srlf) 130mg/26mL solution in single-dose vials will be dispensed to fulfill dose.

Shipping information for IV Loading Dose to be administered by a healthcare provider(Required)

(Note: Shipments cannot be sent to PO boxes)

Street Address Address Line 2 City State ZIP Code

Shipping information for Subcutaneous Loading Dose to be administered by a healthcare provider(Required)

(Note: Shipments cannot be sent to PO boxes)

Street Address Address Line 2 City State ZIP Code

Subcutaneous Maintenance Dose(Required)

IMULDOSA® (ustekinumab-srlf) 90mg/mL PFS Administer 1 injection (90mg) SC every 8 weeks. Quantity: 1 injection

Other

Refill(Required)

Subcutaneous Maintenance Dose(Required)

≤100kg: IMULDOSA® (ustekinumab-srlf) 45mg/0.5mL PFS Administer 1 injection (45mg) SC every 12 weeks. Quantity: 1 injection

>100kg: IMULDOSA® (ustekinumab-srlf) 90mg/mL PFS Administer 1 injection (90mg) SC every 12 weeks. Quantity: 1 injection

Other

Refill(Required)

Subcutaneous Maintenance Dose(Required)

IMULDOSA® (ustekinumab-srlf) 45mg/0.5mL PFS Administer 1 injection (45mg) SC every 12 weeks. Quantity: 1 injection

>100kg w/ mod-severe Plaque Psoriasis: IMULDOSA® (ustekinumab-srlf) 90mg/mL PFS Administer 1 injection (90mg) SC every 12 weeks. Quantity: 1 injection

Other

Refill(Required)

Prescriber Information

Prescriber Name(Required)

First Last

DEA #(Required)

NPI #(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Fax

Contact Person(Required)

First Last

Prescriber Signature Required

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.

Substitutions(Required)

May Substitute/Product Selection Permitted/Substitution Permissible

Dispense 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 & lowa providers, please submit electronic prescription.

Prescriber Signature(Required)

Date(Required)

Month

Day

Year

The information contained in this facsimile may be confidential and is intended solely for the use of the named recipients). 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.

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IMULDOSA® (ustekinumab-srlf) Rx ENROLLMENT FORM

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