SIGN AND FAX THIS FORM TO 877.828.3939
If you have questions, please call 877.627.MEDS (6337)
Prime Specialty Pharmacy NPI: 1457618555
XOLAIR REFERRAL FORM
CLINICAL CONT.
First Name:
MI:
Last Name:
Patient DOB:
Sex:
Address:
City/State/ZIP:
PRESCRIBER
Primary Phone:
Alternate Phone:
PRESCRIBER INFORMATION
Pretreatment serum lgE level_____________
 Allergist
 Pulmonologist
 Pediatrician
 Other:______________________________________________________
PRESCRIPTION INFORMATION
Provider DEA:
Date Needed:
Office Name:
Office Contact:
Deliver To:
Address:
City/State/ZIP:
Fax #:
Primary Insurance:
Policy ID #:
Policyholder Name:
Group #:
Policyholder DOB:
RX PCN:
Secondary Insurance:
Policy ID #:
Policyholder Name:
Group #:
Policyholder DOB:
RX PCN:
RX BIN:
RX BIN:
CLINICAL
Primary Diagnosis:
Height:
ICD10:
Weight:
Allergies
Other Health Conditions:
Test Date: ________________
MD Specialty (required):
Provider NPI:
FAX A COPY OF THE FRONT AND BACK OF ALL INSURANCE CARDS
INSURANCE
Lab Results:  History of positive skin OR RAST test to a perennial aeroallergen
Last Name:
Primary Phone:
CLINICAL
Concomitant Therapies:
Check all that apply:  Short acting beta agonist  Long acting beta agonist  Antihistamines
 Decongestants  Immunotherapy  Inhaled Corticosteroid  Leukotriene modifiers  Oral steroid
 Nasal steroids  Other: ______________________________
First Name:
PRESCRIPTION INFORMATION
PATIENT
PATIENT INFORMATION
/
MEDICATION
/
 ENT
 Primary Care
 New Prescription  Refill Prescription  New to Therapy  Restarting Therapy
 Patient’s Home
STRENGTH
Xolair
 Prescriber’s Office  Other: ______________________
QTY
DIRECTIONS
Every 4 weeks dosing:
 Asthma
(dose dependent on
weight
and lgE levels)
 Adult
150mg
single
use vials
 Pediatric
 CIU
(fixed dose, not
dependent on weight or
lgE)
150mg
single
use vials
 Administer 75mg per dose subcutaneously every 4 weeks.
 Administer 150 mg per dose subcutaneously every 4 weeks.
 Administer 300 mg per dose subcutaneously every 4 weeks.
❑Administer : ______ mg per dose subcutaneously every 4 weeks
Every 2 weeks dosing:
 Administer 225 mg per dose subcutaneously every 2 weeks.
 Administer 300 mg per dose subcutaneously every 2 weeks.
 Administer 375 mg per dose subcutaneously every 2 weeks.
 Administer: ________ mg per dose subcutaneously every 2 weeks.
 Administer 150 mg/dose subcutaneously every 4 weeks.
 Administer 300 mg/dose subcutaneously every 4 weeks.
Supplies:
 10ML Vial of Sterile Water for Injection (1 per vial)
 3ML Luer Lock Injection Syringe
 18G x 1.5in Needle for Reconstitution
 25G x 5/8 in Needle for Subcutaneous Injections
 Send quantity sufficient for medication days supply.
 No supplies needed
Current Medications:
Prescriber Signature and date: Required to validate prescription
___________________________________________________
_____________________________________________________
 Dispense as written/Do not substitute
Date
 Substitution / Brand exchange permitted
Date
For states requiring hand written expressions of product selection use, use this area (e.g., medically necessary, may not substitute, dispense as written, etc.).
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© Prime Therapeutics LLC 07/16 Prime Therapeutics Specialty Pharmacy LLC (Prime Specialty Pharmacy) is a wholly owned subsidiary of Prime Therapeutics LLC.
RF