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 () Talzenna® () Xalkori® (Crizotinib)

Orgovyx (Relugolix) Tarceva® (Erlotinib) Xeloda® ()

Pemazyre™ (Pemigatinib) Tasigna® (Nilotinib) Xermelo™ (Telotristat Ethyl)*

Piqray® () Tazverik™ (Tazemetostat) Xospata® (Gilteritinib)

Retevmo™ (Selpercatinib) Temodar® () Xpovio® (Selinexor)

Rezurock™ (Belumosudil) Tepmetko® (Tepotinib) Xtandi® (Enzalutamide)

Rozlytrek® (Entrectinib) Tibsovo® (Ivosidenib) Yonsa® (Abiraterone Acetate)

Rubraca® () Truseltiq™ (Infigratinib) Zejula® ()

Rydapt® (Midostaurin) Tukysa™ (Tucatinib) Zelboraf® (Vemurafenib)

Sprycel® (Dasatinib) Tykerb® (Lapatinib Ditosylate) Zolinza® ()

Stivarga® (Regorafenib) Ukoniq™ (Umbralisib) Zydelig® ()

Sutent® (Sunitinib Malate) Venclexta® () Zykadia® (ceritinib)

Tabrecta™ (Capmatinib) Verzenio® () 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