Zyvoxassist.com

P at i e n t R e f e R R a l f o R m
ALL FIELDS ARE REQUIRED. compLEtE AnD FAx thIS FoRm to (855) 998-6951. FoR ASSIStAncE oR ADDItIonAL InFoRmAtIon, cALL (855) 239-9869
1. PATIENT INFORMATION
2. INSURANCE INFORMATION
o Patient does not have insurance o Insurance information provided below Name _______________________________ DOB _ _ / _ _ / _ _ _ _ Gender ______ o Copy of both sides of the patient’s insurance card attached Address ______________________________ City _________________________ Primary insurance ____________________ Insurance phone ______________ State ___________ Zip code _______________ E-mail _____________________ Policy ID # ________________________ Group # _________________________ Home phone ________________________ Cell phone _______________________ Policy holder name _________________ Relationship to patient _______________ Work phone _________________________ Best time to contact ______________ Pharmacy plan _______________ Preferred specialty pharmacy _______________ Patient Infor
Patient representative _____________________ Phone ______________________ Policy ID # _______________ Group # ______ RX BIN # ______ RX PCN # ______ 3. MEdICAL PROFILE (INFORMATION NEEdEd FOR PRIOR AUThORIzATION SUPPORT)
Drug allergies ______________________________________________________ Other concurrent medications ___________________________________________ Previously tried and failed therapies ______________________________________ Culture results _____________________________________________________ medication needed by date _ _ / _ _ / _ _ _ _ Height/weight _____________________________________________________ Expected date of discharge _ _ / _ _ / _ _ _ _ 4. PRESCRIPTION INFORMATION
o ZYVox 600 mg tablets
o ZYVox 600 mg oral suspension
escription
For NY Prescribers, please provide prescription on NY state prescription form.
5. PATIENT CASE MANAgER CONTACT INFORMATION
6. PRESCRIbER INFORMATION
ZYVOXassist will utilize the preferred communication method below for outreach
Prescriber name _____________________________ Specialty ________________ regarding patient access to oral ZYVox® (linezolid).
Hospital name _____________________________________________________ escriber
Contact name ______________________________________________________ Collaborating physician _______________________________________________ preferred communication method (please check At LEASt one method)
Address __________________________________________________________ o Phone _______________________________________________ City ___________________________ State ________ Zip code _____________ o fax _________________________________________________ State license # ________________________ NPI # ________________________ o Pager _______________________________________________o E-mail address _________________________________________ This form cannot be processed without physician’s signature below.
7. PRESCRIbER SIgNATURE [ CHECk tO REquESt BENEfItS INvEStIGAtION ONly. If CHECkED, PlEASE SIGN BElOW AND lEAvE RX INfORmAtION BlANk]
By signing this form, I certify that therapy with oral ZYVox is medically necessary for this patient. I will be supervising the patient’s treatment accordingly and I have
reviewed the current oral ZYVox prescribing information. I have received the necessary authorization to release medical and/or other patient information relating to
oral ZYVox therapy to pfizer and its affiliates, service providers, and agents (including US Bioservices) to use and disclose my patient’s health information as necessary
to participate in the ZYVOXassist program, to verify the accuracy of any information provided, to provide reimbursement services, to forward the prescription below to a
pharmacy for fulfillment, and (as applicable) to assess my patient’s eligibility for patient assistance.
Signatur
DoctoR/pREScRIBER SIgnAtURE—DISpEnSE AS WRIttEn
Please see Important Safety Information and indications on reverse side.
P at i e n t R e f e R R a l f o R m
IMPORTANT SAFETY INFORMATION
ZyvOX® (linezolid) use is contraindicated in patients with known hypersensitivity to ZyvOX or any of
A mortality imbalance was seen in an investigational study in ZyvOX-treated patients with catheter-related bloodstream infections. ZyvOX is not approved and should not be used for the ZyvOX should not be used in patients taking any medicinal product which inhibits monoamine treatment of patients with catheter-related bloodstream infections or catheter-site infections. oxidases A or B (e.g. phenelzine, isocarboxazid) or within 2 weeks of taking any such product.
ZyvOX has no clinical activity against Gram-negative pathogens and is not indicated for the treatment of Gram-negative infections. It is critical that specific Gram-negative therapy be myelosuppression (including anemia, leukopenia, pancytopenia, and thrombocytopenia) has been initiated immediately if a concomitant Gram-negative pathogen is documented or suspected.
reported in patients receiving ZyvOX. In cases where the outcome is known, when ZyvOX was Clostridium difficile associated diarrhea has been reported with use of nearly all antibacterial discontinued, the affected hematologic parameters have risen toward pretreatment levels. Complete agents, including ZyvOX, and may range in severity from mild diarrhea to fatal colitis.
blood counts should be monitored weekly in patients who receive ZyvOX, particularly in those who receive ZyvOX for longer than two weeks, those with pre-existing myelosuppression, those receiving unless patients are monitored for potential increases in blood pressure, ZyvOX should not be concomitant drugs that produce bone marrow suppression, or those with a chronic infection who have administered to patients with uncontrolled hypertension, pheochromocytoma, thyrotoxicosis and/or received previous or concomitant antibiotic therapy. Discontinuation of therapy with ZyvOX should be patients taking any of the following: directly and indirectly acting sympathomimetic, vasopressive, considered in patients who develop or have worsening myelosuppression. Peripheral and optic neuropathy have been reported primarily in patients treated with ZyvOX for lactic acidosis has been reported with the use of ZyvOX. Patients receiving ZyvOX who develop longer than the maximum recommended duration of 28 days. If patients experience symptoms of recurrent nausea, vomiting, unexplained acidosis, or a low bicarbonate level should receive immediate visual impairment, prompt ophthalmic evaluation is recommended. If peripheral or optic neuropathy occurs, the continued use of ZyvOX in these patients should be weighed against potential risks. Convulsions have been reported in patients treated with ZyvOX. In some of these cases, a history of Spontaneous reports of serotonin syndrome including fatal cases have been reported with the seizures or risk factors for seizures was reported. co-administration of ZyvOX and serotonergic agents. unless patients are carefully observed for Postmarketing cases of symptomatic hypoglycemia have been reported in patients with diabetes signs and/or symptoms of serotonin syndrome or neuroleptic malignant syndrome-like (NmS-like) mellitus receiving insulin or oral hypoglycemic agents when treated with ZyvOX, a reversible, non- reactions, ZyvOX should not be administered to patients with carcinoid syndrome and/or patients selective mAO inhibitor. While a causal relationship between ZyvOX and hypoglycemia has not been taking any of the following medications: serotonin reuptake inhibitors, tricyclic antidepressants, established, diabetic patients should be cautioned of potential hypoglycemic reactions when treated serotonin 5-Ht1 receptor agonists (triptans), meperidine, bupropion or buspirone. with ZyvOX. If hypoglycemia occurs, a decrease in the dose of insulin or oral hypoglycemic agent, or discontinuation of oral hypoglycemic agent, insulin, or ZyvOX may be required.
In some cases, a patient already receiving a serotonergic antidepressant or buspirone may require urgent treatment with ZyvOX. If alternatives to ZyvOX are not available and the potential benefits of Prescribing ZyvOX in the absence of a proven or strongly suspected bacterial infection or a ZyvOX outweigh the risks of serotonin syndrome or NmS-like reactions, the serotonergic antidepressant prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the should be stopped promptly and ZyvOX administered. the patient should be monitored for two weeks development of drug-resistant bacteria.
(five weeks if fluoxetine was taken) or until 24 hours after the last dose of ZyvOX, whichever comes the most commonly reported adverse events (>2%) in adults across phase 3 clinical trials were first. the patient should also be monitored for discontinuation symptoms of the antidepressant. zYVOX INdICATIONS
ZyvOX formulations are indicated in the treatment of the following infections caused by susceptible
uncomplicated skin and skin structure infections caused by Staphylococcus aureus (methicillin- strains of the designated microorganisms. ZyvOX is not indicated for the treatment of Gram-negative susceptible only) or Streptococcus pyogenes.
infections. It is critical that specific Gram-negative therapy be initiated immediately if a concomitant Community-acquired pneumonia caused by Streptococcus pneumoniae, including cases with Gram-negative pathogen is documented or suspected.
concurrent bacteremia, or Staphylococcus aureus (methicillin-susceptible strains only).
Nosocomial pneumonia caused by Staphylococcus aureus (methicillin-susceptible and -resistant to reduce the development of drug-resistant bacteria and maintain the effectiveness of ZyvOX strains) or Streptococcus pneumoniae. and other antibacterial drugs, ZyvOX should be used only to treat or prevent infections that are Complicated skin and skin structure infections, including diabetic foot infections, without concomitant proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility osteomyelitis, caused by Staphylococcus aureus (methicillin-susceptible and -resistant strains), information are available, they should be considered in selecting or modifying antibacterial therapy. Streptococcus pyogenes, or Streptococcus agalactiae. ZyvOX has not been studied in the treatment of In the absence of such data, local epidemiology and susceptibility patterns may contribute to the vancomycin-Resistant Enterococcus faecium infections, including cases with concurrent bacteremia.
Pfizer’s service provider performing ZYVOXassist support services provides patient insurance services tries to provide correct information, it and Pfizer Inc make no representations or benefits verification as a service under contract for Pfizer Inc. ZYVOXassist support services warranties, expressed or implied, as to the accuracy of the information. the support services assist health care professionals in the determination of whether treatment could be covered by administrator, Pfizer Inc, or its employees or agents shall in no event be liable for any damages the applicable third-party payer based on coverage guidelines provided by the payer, and resulting from or relating to the services. Responsibility for the use of this service is agreed patient information provided by the health care provider under appropriate authorization upon and accepted by all providers and other users of this information.
following the provider’s exclusive determination of medical necessity.
Pfizer Inc does not guarantee, and assumes no responsibility for the quality, scope, or many factors affect third-party reimbursement. Pfizer Inc and Pfizer’s service provider availability of the ZYVOXassist support services including but not limited to reimbursement performing the ZYVOXassist support services make no representation or guarantee that support services, patient education, and other support services. ZYVOXassist support services insurance reimbursement or any other payment will be available. this service is for are included within the cost of the product, and have no independent value to providers apart informational purposes only. While Pfizer’s service provider performing ZYVOXassist support

Source: http://www.zyvoxassist.com/files/pdf-files/ZVU574410_ZYVOXassist%20Patient%20Referral%20Form_Fillable_FINAL.pdf