SUMAVEL® Express
Service Request Form
N
Please complete as much of this form as possible to ensure
efficient prescription processing
Please Fax Toll Free to 1-877-848-6177
INDICATION and Usage
SUMAVEL® DosePro® (sumatriptan injection) is indicated in adults for (1) the acute treatment of migraine, with or without aura,
and (2) the acute treatment of cluster headache
Limitations of Use:
• Use only if a clear diagnosis of migraine or cluster headache has been established
• If a patient has no response to the first migraine attack treated with SUMAVEL® DosePro®, reconsider the diagnosis of migraine
before SUMAVEL® DosePro® is administered to treat any subsequent attacks
• SUMAVEL® DosePro® is not indicated for the prevention of migraine attacks
IMPORTANT SAFETY INFORMATION about SUMAVEL® DosePro®
SUMAVEL® DosePro® is contraindicated in patients with:
• Ischemic coronary artery disease (CAD) (e.g., angina
pectoris, history of myocardial infarction, or documented
silent ischemia), or coronary artery vasospasm, including
Prinzmetal’s angina
• Wolff-Parkinson-White Syndrome or arrhythmias associated
with other cardiac accessory conduction pathway disorders
• History of stroke, transient ischemic attack (TIA) because these
patients are at a higher risk of stroke
• History of hemiplegic or basilar migraine
• Peripheral vascular disease
• Ischemic bowel disease
• Uncontrolled hypertension
• Recent use (i.e., within 24 hours) of another 5-HT1 agonist,
an ergotamine-containing or ergot-type medication such as
dihydroergotamine (DHE) or methysergide
• Concurrent use of an MAO-A inhibitor or recent (within 2
weeks) use of an MAO-A inhibitor
• Hypersensitivity to SUMAVEL® DosePro® (angioedema and
anaphylaxis seen)
There have been rare reports of serious cardiac adverse
reactions, including acute myocardial infarction, occurring within
a few hours following administration of SUMAVEL® DosePro®.
SUMAVEL® DosePro® may cause coronary artery vasospasm
(Prinzmetal’s angina). These types of reactions have occurred in
some patients without known CAD
For triptan-naïve patients with multiple cardiovascular risk factors who
have a negative cardiovascular evaluation, consider administrating the
first SUMAVEL® DosePro® dose in a medically-supervised setting
and performing an electrocardiogram (ECG) immediately following
SUMAVEL® DosePro® administration. For such patients, consider
periodic cardiovascular evaluation in intermittent long-term users of
SUMAVEL® DosePro®
Life-threatening arrythmias have been reported within a few
hours following the administration of 5-HT1 agonists.
Discontinue SUMAVEL® DosePro® if these disturbances occur
Sensations of tightness, pain, pressure, and heaviness have been
reported in the chest, throat, neck, and jaw after treatment with
SUMAVEL® DosePro® and are usually non-cardiac in origin
Cerebrovascular events, some fatal; non-coronary vasospastic
reactions such as peripheral or gastrointestinal vascular
ischemia and Raynaud’s syndrome; and increases in blood
pressure have been reported in patients treated with 5-HT1
agonists. Monitor blood pressure in patients treated with
SUMAVEL® DosePro®
Overuse of acute migraine drugs may lead to exacerbation of
headache (medication overuse headache). Detoxification of
patients, including withdrawal of the overused drugs, and
treatment of withdrawal symptoms may be necessary
Serotonin syndrome may occur with SUMAVEL® DosePro®
particularly during combined use with selective serotonin reuptake
inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors
(SNRIs), tricyclic antidepressants (TCAs), and monoamine oxidase
(MAO) inhibitors. Discontinue SUMAVEL® DosePro® if serotonin
syndrome is suspected
In controlled clinical trials with sumatriptan injection, the most
common adverse reactions (≥5% and >placebo) were injection
site reactions, tingling, dizziness/vertigo, warm/hot sensation,
burning sensation, feeling of heaviness, pressure sensation,
flushing, feeling of tightness, and numbness
Please see accompanying full Prescribing Information.
Rx Only
SUMAVEL is a registered trademark of Endo Ventures Bermuda LTD.
DosePro is a registered trademark of Zogenix, Inc.
Distributed by: Endo Pharmaceuticals Inc.
Manufactured for: Endo Ventures LTD (Ireland)
Manufactured by: Zogenix, Inc.
© 2014 Endo Pharmaceuticals Inc. All Rights Reserved. Malvern, PA 19355
SD-03250b/August 2014 www.sumaveldosepro.com 1-800-462-ENDO (3636)
SUMAVEL® Express – Please Fax Toll Free to 1-877-848-6177 when completed
(PLEASE COMPLETE AS MUCH OF THIS FORM AS POSSIBLE TO ENSURE EFFICIENT PRESCRIPTION PROCESSING)
PATIENT INFORMATION
(PLEASE PRINT)
Gender:
Patient Name (required):
FIRST NAME
LAST NAME
F
M
Date of Birth (required):
MI
Address:
(MM/DD/YEAR)
Best Number to Call (required):
City:
State:
Zip:
Best Time to Call (AM/PM):
Email:
Alternative Number:
This email address may be used by SUMAVEL® Express to communicate important updates regarding the status of this request and will not be used/shared for any other purpose.
INSURANCE INFORMATION
(PLEASE INCLUDE A COPY OF PATIENT’S INSURANCE AND PRESCRIPTION CARDS WITH FORM)
Prescription Insurance:
Cardholder Name:
ID#:
Group #:
PCN:
RxBin #:
Phone:
Primary Medical Insurance:
Cardholder Name:
ID#:
Group #:
Phone:
CLINICAL INFORMATION
CURRENT MEDICATIONS: ________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Patient has vomiting, gastric stasis, or intolerance to oral therapy
Patient requires SQ therapy, has needle phobia
Patient has had previous ER visit for migraine
Morning migraine that has advanced in severity prior to waking
Vision disturbance prevents patient from following StatDose or generic kit
Drug Allergies:
instructions or assembly
Drugs patient has tried previously (if available, please attach applicable clinical notes or chart):
Axert®
Relpax®
Frova®
Amerge®
Maxalt®
Zomig®
Treximet®
Imitrex®:
Oral
Inj.
Nasal Spray
Please provide any additional reasons for the non-formulary drug request (please check all that apply):
New therapy
Continuation, date started:
(MM/DD/YEAR)
Other:
PROVIDER INFORMATION (PLEASE PRINT)
Provider Name:
Provider Specialty:
Practice Name:
Phone:
Fax:
Address:
City:
State:
NPI# (required):
DEA# (required):
Zip:
Email:
This email address may be used by SUMAVEL® Express to communicate important updates regarding the status of this request and will not be used/shared for any other purpose.
Contact Phone:
PRESCRIPTION INFORMATION
Rx: SUMAVEL® DosePro®
ICD-9 Code:
NDC 43376-106-06
346.0 Migraine with Aura
346.1 Migraine without Aura
339.00-03 Cluster Headache
Sig:
Other:
Maximum Usage:
Volume/Strength: 6 mg/0.5 mL per unit
Quantity:
/week
DAW
I certify that this therapy is medically necessary and that this information is accurate to the best of my knowledge.
Prescriber’s Signature:
Date:
PROVIDER AUTHORIZATION AND BUSINESS ASSOCIATE AGREEMENT
®
investigations and other payment and healthcare operation functions on my behalf (“Services”). Hub may also use and disclose PHI: (i) to de-identify it, and use and disclose such information as permitted by law; (ii) for its
own proper administration and to carry out its responsibilities in accordance with 45 CFR 164.504(e)(2)&(4); (iii) as otherwise permitted by law.
Hub agrees (and agrees to require that its applicable subcontractors agree) to: (A) not use or disclose PHI other than as provided herein or as required by law; (B) use appropriate safeguards to protect PHI and comply with
the Security Rule; (C) report to me any use or disclosure not provided for herein, including any breaches of which it becomes aware; (D) make available PHI, amend or incorporate amendments of PHI in a designated record
set and provide an accounting of disclosures in accordance with 45 CFR 164.524, and 528 respectively; (E) to the extent delegated hereunder, carry out my obligations under the Privacy Rule in accordance with the
requirements therein that apply to me; (F) make its internal practices and records regarding PHI available to the secretary; and (G) upon termination of the services, either return or destroy the PHI obtained hereunder or
limit further uses and disclosures to those purposes that make its return or destruction infeasible and continue to protect it; and (H) authorize me to terminate the Services if Hub has violated a material term herein.
I understand
that Endo Pharmaceuticals Inc. provides funding for the various services performed by Hub.
Prescriber’s Signature:
Date:
Occam Health Signature:
Date:
For questions about this program, please call: 1-888-702-1983
INDICATION and Usage
SUMAVEL® DosePro® (sumatriptan injection) is indicated in adults for (1) the acute treatment of migraine, with or without aura, and (2) the acute treatment of cluster headache
Limitations of Use:
• Use only if a clear diagnosis of migraine or cluster headache has been established
• If a patient has no response to the first migraine attack treated with SUMAVEL® DosePro®, reconsider the diagnosis of migraine before SUMAVEL® DosePro® is
administered to treat any subsequent attacks
• SUMAVEL® DosePro® is not indicated for the prevention of migraine attacks
IMPORTANT SAFETY INFORMATION about SUMAVEL® DosePro®
There have been rare reports of serious cardiac adverse reactions, including acute myocardial infarction, occurring within a few hours following administration of
SUMAVEL® DosePro®. SUMAVEL® DosePro® may cause coronary artery vasospasm (Prinzmetal’s angina). These types of reactions have occurred in some patients without known CAD
Please see accompanying full Prescribing Information.
SD-03250b/August 2014