converted IMFINZI Enrollment Form A multi-page enrollment form to capture necessary patient, provider, and prescription information to start a new request for support. The IMFINZI Enrollment Form must be signed by the patient to utilize Access 360 patient-specific support. 163 0 obj endobj <> endobj 154 0 obj There are no contraindications for IMFINZI ® (durvalumab).. Immune-Mediated Adverse Reactions. 167 0 obj 166 0 obj Patient Authorization I authorize my health care providers (HCPs) and staff, my health … <> <> false <>stream 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 … 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 … When using the enrollment portal, at the completion of the enrollment … Call 1-800-292-6363 Monday–Friday, 9:00 am to 6:00 pm EST or visit www.azandmeapp.com Non-Specialty Products Fax: … 444 0 obj <>stream See the Dosing section to identify the number of vials needed. endobj 3 Fax Referral Form … 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). 162 0 obj / endobj endobj 169 0 obj IMFINZI is a prescription medicine used to treat adults with a type of lung cancer called non-small cell lung cancer (NSCLC).IMFINZI may be used when your NSCLC has not spread outside your chest, … Imfinzi is a form of immunotherapy containing durvalumab, a monoclonal antibody that blocks programmed cell death ligand-1 (PD-L1). Imfinzi. xmp.did:11060ec6-5e9f-4a46-a268-e4815d3e6ec8 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 … 2018-07-31T09:56:59.553-05:00 159 0 obj Then, fill in the required prescription and enrollment information and fax it to us at the number printed on the form. endstream endobj startxref xmp.id:DE0AF0EB29206811822AB634F0DC0EC0 The AZ&Me Prescription Savings program is designed to help qualifying patients, including those who receive their medications through participating healthcare facilities. There are no contraindications for IMFINZI ® (durvalumab).. Immune-Mediated Adverse Reactions. xmp.iid:DBC29F2F2720681188C6FB56A0F3D044 The specific … 160 0 obj 1190 0 obj 179 0 obj <> endobj The generic name of Imfinzi is durvalumab. 168 0 obj 165 0 obj Adobe InDesign CS6 (Macintosh) [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 R 1096 0 R 1096 0 R 1096 0 R 1096 0 R 1096 0 R 1106 0 R 1097 0 R 1097 0 R 1097 0 R 1097 0 R 1097 0 R 1105 0 R 1098 0 R 1098 0 R 1098 0 R 1098 0 R 1104 0 R 1099 0 R 1099 0 R 1099 0 R 1099 0 R 1099 0 R 1099 0 R 1103 0 R 1100 0 R 1100 0 R 1100 0 R 1100 0 R 1100 0 R 1102 0 R 1101 0 R 1101 0 R 1101 0 R 1101 0 R 1101 0 R 1167 0 R 1167 0 R 1167 0 R 1168 0 R 1168 0 R 1168 0 R 1169 0 R 1169 0 R 1169 0 R 1170 0 R 1170 0 R 1170 0 R 1171 0 R 1171 0 R 1171 0 R 1181 0 R 1182 0 R 1181 0 R 1181 0 R 1179 0 R 1179 0 R 1180 0 R 1179 0 R 1177 0 R 1178 0 R 1177 0 R 1176 0 R 1184 0 R 248 0 R] 2018-02-15T11:05:50.000-06:00 xmp.did:11060ec6-5e9f-4a46-a268-e4815d3e6ec8 Imfinzi 120 mg/2.4 mL single-dose vial: 00310-4500-xx Imfinzi 500 mg/10 mL single-dose vial: 00310-4611-xx . 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 Dosing for IMFINZI is weight-based so the dose will vary by patient, and may be provided through a combination of vial sizes. %PDF-1.7 %âãÏÓ 2 5 6 3 AstraZeneca Access 360™ Enrollment Form Please complete form, sign, and fax all pages to 1-844-329-2360. <> <> false <> [null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null 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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This administration takes about 60 minutes per session, and these sessions occur every two to four weeks. Connect Your IMFINZI … Imfinzi is administered via IV in the hospital and does not come in a pill form. endstream <. endobj endobj Incomplete fields may delay the start of treatment. GET STARTED. 164 0 obj Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials [see Clinical Studies (14.1)]. 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236 0 R 237 0 R 238 0 R 239 0 R 240 0 R 241 0 R 242 0 R 243 0 R 244 0 R] 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� Hi All! 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Imfinzi offers may be in the form of a printable coupon, rebate, savings card, trial offer, or free samples. 2017-11-01T21:18:13.000+05:30 endobj Download IMFINZI Enrollment Forms and Resources. endobj 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. default <> Important immune-mediated adverse reactions listed under Warnings … 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. endobj <>/Metadata 1247 0 R/Outlines 154 0 R/Pages 1187 0 R/StructTreeRoot 155 0 R/Type/Catalog/ViewerPreferences<>>> 9cb95b8b5a82d8702cdc43adcf2e16e50d47a5f3 Patient Authorization I authorize my health care providers (HCPs) and staff, my health … 1187 0 obj endobj The product's dosage form is injection, solution and is administered via intravenous form… 2 Complete the rest of the Referral Form Please fill out all required fields of the Referral Form. 155 0 obj <> 2017-11-01T09:48:13.000-06:00 DOWNLOAD IN ENGLISH DOWNLOAD IN SPANISH Click here to fill out the form online. AstraZeneca Access 360™ Enrollment Form Please complete form, sign, and fax all pages to 1-844-329-2360. Page 4 | IMFINZI® (durvalumab) Prior Auth Criteria Proprietary Information. 170 0 obj <> Important Safety Information. Important immune-mediated adverse reactions listed under Warnings … 2018-07-31T09:57:12.155-05:00 Imfinzi Coupons and Rebates. Ensure your patients are enrolled to receive assistance and find IMFINZI coding and reimbursement materials. Imfinzi … from application/x-indesign to application/pdf endobj 157 0 obj Adobe InDesign CS6 (Macintosh) 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.. uuid:f75bf3a8-44aa-4a0d-9047-0c1da5ca42a7 0 Restricted … Happy to report that I have finished my standard chemo and radiation treatments and will likely be starting on Imfinzi (Durvamulab) probably in September. 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. 1247 0 obj PD-L1 is a protein that’s overexpressed by cancer … endobj A multi-page enrollment form to capture necessary patient, provider, and prescription information to start a new request for support. <> Some offers may be printed right from a website, others require … 2 DOSAGE AND ADMINISTRATION 2.1 Recommended Dosage The recommended dosages for IMFINZI as a single agent and IMFINZI … [null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null 944 0 R 945 0 R 946 0 R 947 0 R 948 0 R 949 0 R 950 0 R 951 0 R 952 0 R 953 0 R 954 0 R 955 0 R 956 0 R 957 0 R 958 0 R 959 0 R 935 0 R 926 0 R 927 0 R 928 0 R 929 0 R 930 0 R 931 0 R 932 0 R 933 0 R 934 0 R 916 0 R 917 0 R 918 0 R 919 0 R 920 0 R 921 0 R 922 0 R 923 0 R 924 0 R 925 0 R 911 0 R 912 0 R 913 0 R 914 0 R 915 0 R 910 0 R 909 0 R 906 0 R 907 0 R 908 0 R 903 0 R 904 0 R 905 0 R 936 0 R 940 0 R 938 0 R 942 0 R 863 0 R 864 0 R 854 0 R 855 0 R 856 0 R 857 0 R 858 0 R 859 0 R 860 0 R 861 0 R 862 0 R 841 0 R 842 0 R 843 0 R 844 0 R 845 0 R 846 0 R 847 0 R 848 0 R 849 0 R 850 0 R 851 0 R 852 0 R 853 0 R 892 0 R 891 0 R 890 0 R 887 0 R 886 0 R 888 0 R 889 0 R 882 0 R 883 0 R 884 0 R 885 0 R 881 0 R 880 0 R 879 0 R 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 PDF Library 10.0.1 %PDF-1.7 %���� 2018-02-15T12:05:50.000-05:00 Referral forms To begin the referral process, find the referral form by specialty condition and product name in the list below. Application for Free AstraZeneca Medicines Page 3 of 5 Questions? Important Safety Information. endobj Attach a front and back copy of the patient’s insurance and drug/prescription benefit cards (if available). endobj 161 0 obj 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 endobj Select Safety Information. application/pdf proof:pdf
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