AstraZeneca Access 360™ Enrollment Form Please complete form, sign, and fax all pages to 1-844-329-2360. <> endobj Surgery was discussed … Attach a front and back copy of the patient’s insurance and drug/prescription benefit cards (if available). 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241 0 R 242 0 R 243 0 R 244 0 R] Imfinzi with NDC 0310-4500 is a a human prescription drug product labeled by Astrazeneca Pharmaceuticals Lp. 2018-02-15T11:05:50.000-06:00 Connect Your IMFINZI … There are no contraindications for IMFINZI ® (durvalumab).. Immune-Mediated Adverse Reactions. 164 0 obj / Referral forms To begin the referral process, find the referral form by specialty condition and product name in the list below. proof:pdf Imfinzi Coupons and Rebates. endobj 155 0 obj IMFINZI, in combination with etoposide and either carboplatin or cisplatin, is indicated for the first-line treatment of adult patients with extensive-stage small cell lung cancer (ES-SCLC). endobj h�bbd```b``����A$�Y0[L��n`q�X�� ��DV��Y 6G̾f��e�"�`F��*��U6�2��܃�w5�v��xEp����ރD�>{0ܹ�d�/�C|5��ơ3�V�0W���.. "���H�Xɳ���g�C,Ψf����`�sA$�/�!a ���$��k�z0Rr���m��l~�4�x�M�FF{��`�&R�2�������{�i(3J���$���g`.` ��P� endobj Ensure your patients are enrolled to receive assistance and find IMFINZI coding and reimbursement materials. If approved, Imfinzi … endobj The AZ&Me Prescription Savings program is designed to help qualifying patients, including those who receive their medications through participating healthcare facilities. The specific … Specialty Distributors (SD): The IMFINZI … <>/A1<>/A10<>/A11<>/A12<>/A2<>/A4<>/A5<>/A7<>/A8<>/A9<>/Pa0<>/Pa1<>/Pa10<>/Pa11<>/Pa12<>/Pa2<>/Pa3<>/Pa4<>/Pa7<>>> 156 0 obj Page 4 | IMFINZI® (durvalumab) Prior Auth Criteria Proprietary Information. <. xmp.did:B71D21B42620681188C6FB56A0F3D044 163 0 obj When using the enrollment portal, at the completion of the enrollment … Restricted … Imfinzi is a form of immunotherapy containing durvalumab, a monoclonal antibody that blocks programmed cell death ligand-1 (PD-L1). 1247 0 obj IMFINZI ® (durvalumab) 120 mg/2.4 mL vial Quantity: ... Enrollment Form: Buy and Bill (prescription information does not need to be completed) I authorize Access 360 program to convey the attached … Download IMFINZI Enrollment Forms and Resources. uuid:f75bf3a8-44aa-4a0d-9047-0c1da5ca42a7 Imfinzi is indicated for the treatment of patients with locally advanced or metastatic urothelial carcinoma who:This indication is approved under accelerated approval based on tumor response rate and duration of response. xmp.did:11060ec6-5e9f-4a46-a268-e4815d3e6ec8 false converted 160 0 obj Then, fill in the required prescription and enrollment information and fax it to us at the number printed on the form. 2017-11-01T21:18:13.000+05:30 The IMFINZI Enrollment Form must be signed by the patient to utilize Access 360 patient-specific support. Imfinzi (durvalumab) is a human monoclonal antibody that binds to PD-L1 and blocks the interaction of PD-L1 with PD-1 and CD80, countering the tumour's immune-evading tactics and releasing the inhibition of immune responses. 2 5 6 3 AstraZeneca Access 360™ Enrollment Form Please complete form, sign, and fax all pages to 1-844-329-2360. 3 Fax Referral Form … 2017-11-01T09:48:13.000-06:00 <> 1187 0 obj Imfinzi offers may be in the form of a printable coupon, rebate, savings card, trial offer, or free samples. Patient Authorization I authorize my health care providers (HCPs) and staff, my health … DOWNLOAD IN ENGLISH DOWNLOAD IN SPANISH Click here to fill out the form online. 179 0 obj <> endobj 158 0 obj Application for Free AstraZeneca Medicines Page 3 of 5 Questions? 165 0 obj %PDF-1.7 %âãÏÓ endobj endobj xmp.id:DE0AF0EB29206811822AB634F0DC0EC0 Hi All! <>stream endobj Adobe PDF Library 10.0.1 Some offers may be printed right from a website, others require … 170 0 obj endobj AstraZeneca's Imfinzi (durvalumab) has received acceptance for its supplemental Biologics License Application (sBLA) and has also been granted Priority Review in the US for a new four-week, fixed-dose regimen for treatment in the approved indications of non-small cell lung cancer (NSCLC) and bladder cancer.. application/pdf 169 0 obj 6 161 0 obj 162 0 obj 397865 IMFINZI Enrollment Form A multi-page enrollment form to capture necessary patient, provider, and prescription information to start a new request for support. You can download a blank application, print it out and then fill in your information by hand; or, you can fill in the application on your computer screen by selecting "Fill in Application & Print", clicking on the … endobj Patient Authorization I authorize my health care providers (HCPs) and staff, my health … 314 0 obj <>/Filter/FlateDecode/ID[<090CFB5FEDF941E2B760A9CE7E5194E6><56ACEE6F7F784F44AB982FDE6ECD82FB>]/Index[179 266]/Info 178 0 R/Length 265/Prev 387049/Root 180 0 R/Size 445/Type/XRef/W[1 3 1]>>stream endobj Call 1-800-292-6363 Monday–Friday, 9:00 am to 6:00 pm EST or visit www.azandmeapp.com Non-Specialty Products Fax: … Adobe PDF Library 10.0.1 endstream endobj startxref PD-L1 is a protein that’s overexpressed by cancer … 0 Imfinzi 120 mg/2.4 mL single-dose vial: 00310-4500-xx Imfinzi 500 mg/10 mL single-dose vial: 00310-4611-xx . false DOWNLOAD IN ENGLISH DOWNLOAD IN SPANISH Click here to fill out the Patient Authorization Form … 157 0 obj <> See the Dosing section to identify the number of vials needed. Incomplete fields may delay the start of treatment. 2018-07-31T09:56:59.553-05:00 Important immune-mediated adverse reactions listed under Warnings … This administration takes about 60 minutes per session, and these sessions occur every two to four weeks. GET STARTED. The generic name of Imfinzi is durvalumab. 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878 0 R 877 0 R 876 0 R 875 0 R 874 0 R 894 0 R 893 0 R 961 0 R 275 0 R 836 0 R 837 0 R] Adobe InDesign CS6 (Macintosh) Dosing for IMFINZI is weight-based so the dose will vary by patient, and may be provided through a combination of vial sizes. 2018-02-15T12:05:50.000-05:00 444 0 obj <>stream Adobe InDesign CS6 (Macintosh) [null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null 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2018-07-31T09:57:12.155-05:00 endobj Important Safety Information. endstream There are no contraindications for IMFINZI ® (durvalumab).. Immune-Mediated Adverse Reactions. Imfinzi is administered via IV in the hospital and does not come in a pill form. endobj Imfinzi … xmp.iid:DBC29F2F2720681188C6FB56A0F3D044 Imfinzi (durvalumab) is a human monoclonal antibody that binds to PD-L1 and blocks the interaction of PD-L1 with PD-1 and CD80, countering the tumour's immune-evading tactics … endobj 168 0 obj IMFINZI ® (durvalumab) is a prescription medicine used to treat adults with Stage III unresectable non-small cell lung cancer (NSCLC) whose disease has not progressed … <> h�b``�e``Ue`g`�Z b�/P������ PŚ{EO��R[��u��W��W���ww�t��WN�. Select Safety Information. endobj [null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null 1069 0 R 1067 0 R 1071 0 R 1073 0 R 1074 0 R 1075 0 R 1076 0 R 1077 0 R 1078 0 R 1079 0 R 1080 0 R 1081 0 R 1082 0 R 1083 0 R 1084 0 R 1085 0 R 1086 0 R 1087 0 R 1088 0 R 263 0 R 1005 0 R 1007 0 R 1005 0 R 1005 0 R 1006 0 R 1064 0 R 1065 0 R 1061 0 R 1062 0 R 1063 0 R 1044 0 R 1045 0 R 1046 0 R 1047 0 R 1048 0 R 1049 0 R 1050 0 R 1051 0 R 1052 0 R 1053 0 R 1054 0 R 1055 0 R 1056 0 R 1057 0 R 1058 0 R 1059 0 R 1060 0 R 1042 0 R 1043 0 R 1035 0 R 1036 0 R 1037 0 R 1032 0 R 1033 0 R 1034 0 R 1029 0 R 1030 0 R 1031 0 R 1026 0 R 1027 0 R 1028 0 R 1019 0 R 1020 0 R 1021 0 R 1016 0 R 1017 0 R 1018 0 R 1011 0 R 1012 0 R 1013 0 R 1014 0 R 1015 0 R 1090 0 R 963 0 R 964 0 R 1004 0 R 972 0 R 973 0 R 974 0 R 975 0 R 976 0 R 977 0 R 978 0 R 979 0 R 980 0 R 981 0 R 982 0 R 983 0 R 984 0 R 985 0 R 986 0 R 987 0 R 988 0 R 989 0 R 990 0 R 991 0 R 992 0 R 993 0 R 994 0 R 995 0 R 996 0 R 997 0 R 998 0 R 999 0 R 1000 0 R 1001 0 R 1002 0 R 1003 0 R 967 0 R 967 0 R 967 0 R 971 0 R 967 0 R 968 0 R 968 0 R 968 0 R 969 0 R 969 0 R 969 0 R 970 0 R 969 0 R] endobj The product's dosage form is injection, solution and is administered via intravenous form… <> Important Safety Information. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials [see Clinical Studies (14.1)]. Important immune-mediated adverse reactions listed under Warnings … [null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null 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654 0 R 655 0 R 656 0 R 657 0 R 658 0 R 659 0 R 660 0 R 661 0 R 662 0 R 663 0 R 664 0 R 665 0 R 666 0 R 667 0 R] %PDF-1.7 %���� IMPORTANT: This form cannot be used to enroll patients into the IMFINZI ® (durvalumab) or FASLODEX (fulvestrant) Patient Savings Program; patients must be enrolled into those programs via the enrollment portal. 9cb95b8b5a82d8702cdc43adcf2e16e50d47a5f3 [1172 0 R 1173 0 R 1175 0 R 1173 0 R 1174 0 R 1151 0 R 1152 0 R 1153 0 R 1154 0 R 1155 0 R 1156 0 R 1157 0 R 1158 0 R 1159 0 R 1160 0 R 1161 0 R 1162 0 R 1163 0 R 1164 0 R 1165 0 R 1125 0 R 1126 0 R 1127 0 R 1128 0 R 1129 0 R 1130 0 R 1131 0 R 1132 0 R 1133 0 R 1134 0 R 1135 0 R 1136 0 R 1137 0 R 1138 0 R 1139 0 R 1140 0 R 1141 0 R 1142 0 R 1143 0 R 1144 0 R 1145 0 R 1146 0 R 1147 0 R 1148 0 R 1149 0 R 1150 0 R 1166 0 R 1092 0 R 1093 0 R 1186 0 R 1120 0 R 1120 0 R 1121 0 R 1120 0 R 1120 0 R 1122 0 R 1114 0 R 1115 0 R 1116 0 R 1117 0 R 1118 0 R 1119 0 R 1108 0 R 1109 0 R 1110 0 R 1111 0 R 1112 0 R 1113 0 R 1107 0 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Referral Form Please fill out all required fields of the Referral Form. 1190 0 obj 2 DOSAGE AND ADMINISTRATION 2.1 Recommended Dosage The recommended dosages for IMFINZI as a single agent and IMFINZI … endobj from application/x-indesign to application/pdf Happy to report that I have finished my standard chemo and radiation treatments and will likely be starting on Imfinzi (Durvamulab) probably in September. <>/Metadata 1247 0 R/Outlines 154 0 R/Pages 1187 0 R/StructTreeRoot 155 0 R/Type/Catalog/ViewerPreferences<>>>
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