ORAL ONCOLOGY (O-Z)
Chartwell Specialty Pharmacy Phone: 1-800-366-6020 Fax: 412-920-1869
Date:______Auth #: Auth Dates: UPMC prior auth form attached Patient Information
First Name: ______Last Name: ______DOB: ______SSN: ______Male Female Address: ______City: ______State:______Zip: ______Phone: ______Alternate Phone: ______Caregiver/ Emergency Contact: ______Phone: ______Weight: ______Allergies: ______Latex Allergy: Yes No
Insurance Information
Primary Insurance: ______Secondary Insurance: ______Insured: ______Insured: ______Phone:______Phone:______Policy #: ______Group #: ______Policy #: ______Group #: ______
ICD-10
ICD-10 Code: Diagnosis:
Prescription Information
Odomzo® (Sonidegib Phosphate) Tagrisso® (Osimertinib Mesylate) Votrient® (Pazopanib HCI)
Onureg (Azacitidine) Talzenna® (Talazoparib) Xalkori® (Crizotinib)
Orgovyx (Relugolix) Tarceva® (Erlotinib) Xeloda® (Capecitabine)
Pemazyre™ (Pemigatinib) Tasigna® (Nilotinib) Xermelo™ (Telotristat Ethyl)*
Piqray® (Alpelisib) Tazverik™ (Tazemetostat) Xospata® (Gilteritinib)
Retevmo™ (Selpercatinib) Temodar® (Temozolomide) Xpovio® (Selinexor)
Rezurock™ (Belumosudil) Tepmetko® (Tepotinib) Xtandi® (Enzalutamide)
Rozlytrek® (Entrectinib) Tibsovo® (Ivosidenib) Yonsa® (Abiraterone Acetate)
Rubraca® (Rucaparib) Truseltiq™ (Infigratinib) Zejula® (Niraparib)
Rydapt® (Midostaurin) Tukysa™ (Tucatinib) Zelboraf® (Vemurafenib)
Sprycel® (Dasatinib) Tykerb® (Lapatinib Ditosylate) Zolinza® (Vorinostat)
Stivarga® (Regorafenib) Ukoniq™ (Umbralisib) Zydelig® (Idelalisib)
Sutent® (Sunitinib Malate) Venclexta® (Venetoclax) Zykadia® (ceritinib)
Tabrecta™ (Capmatinib) Verzenio® (Abemaciclib) Zytiga® (Abiraterone Acetate)
Tafinlar® (Dabrafenib Mesylate) Vizimpro® (Dacomitinib)
Dose/ Strength Directions Quantity Refills
Prescriber Information
Date Shipment Needed: ______Ship to: Patient Physician/ Clinic Other:______Physician’s Name: ______Office Contact Name:______Phone: ______Fax: ______Address: ______City: ______State: ______Zip: ______Physician’s Signature: ______Date: ______
I authorize Chartwell Pennsylvania Specialty Pharmacy and its representatives to act as an agent and execute the insurance prior authorization process. Updated: 08/16/21