Celgene Patient Physician Agreement Form

For each of your subsequent recipes, you need to follow a similar process. Detailed information on the requirements of the POMALYST REMS program® can be found in or in the POMALYST REMS patient guide® program. For eligible patients with commercial or private insurance (including health scholarships)*, the liability for the REVLIMID supplement is reduced to $25 (subject to the annual cap). Your doctor will advise you on why and how you and your partner should avoid pregnancy. Your doctor will also inform you not to share the medicine, not to donate blood or semen, and the proper use of contraceptives. You should be responsible for not treating POMALYST® (pomalidomide) capsules Depending on your patient`s insurance situation, there are programs and organizations that can help pay FOR REVLIMID. The prescribing physician/patient completes the corresponding mandatory confidential survey for qualified patients who are uninsured or underinsured: REVLIMID may be available free of charge.† The certified pharmacy gives REVLIMID with a patient medication guide from your specialist can provide you with information about independent third-party organizations† that can help you cover the costs: The prescribing physician fills out with each patient one® patient-physician agreement form (lenalidomide) and sends it to Celgene The prescribing physician receives an authorization number from Celgene and writes it down on each prescription, in association with the patient`s risk category The prescribing physician verifies the negative pregnancy test for all women with reproductive potential Two negative pregnancy tests must be performed before the start of treatment. The first test should be performed within 10 to 14 days and the second within 24 hours before prescribing treatment with POMALYST, then weekly the first month, then monthly in women with regular menstrual cycles or every 2 weeks in women with irregular menstrual cycles. Your doctor sends your prescription to a specialty pharmacy In order to avoid serious risks to unborn babies, POMALYST is only available through a limited distribution program called POMALYST Risk Evaluation and Mitigation Strategy (REMS). If you have commercial insurance, you can qualify for celgene Commercial Co-pay program....

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