Faxed prescriptions can only be accepted from a prescribing practitioner. Pharmacy 877.662.6633 e-prescribe to: Onco360 Oncology Pharmacy Louisville, KY NPI# 1437577988 Fax 877.662.6355

Oral Rx Oncology Order Form

Patient Information (REQUIRED) Date: ______Patient Name: Date of Birth: Sex:  M  F Last 4 Digits of SSN: Address: City: State: Zip: Home Ph: Cell Ph: Email: Patient Weight: lbs. Patient Height: Allergies:

Pharmacy Benefit Manager (REQUIRED) Please provide copies of both sides of the patient’s card(s) PBM Name: Rx BIN# PCN#: Rx Group# :Member ID#:

Medical/Health Insurance Info. (REQUIRED) Please provide copies of both sides of the patient’s card(s) Primary: Policy Holder: Policy # Ph: Address: City: State: Zip: Secondary: Policy Holder: Policy # Ph: Address: City: State: Zip:

Oral Medication Quantity

 Abiraterone Acetate  Erleada™ (apalutamide)  Lenvima® (lenvatinib)  Rozlytrek™ (entrectinib)  Varubi® (rolapitant)  Xpovio™ (selinexor)  Lonsurf®  Afinitor® (everolimus)  Erlotinib  Rydapt® (midostaurin)  Venclexta® (venetoclax)  Xtandi® (enzalutamide) (trifluridine and tipiracil) ®  Akynzeo ® ® ® ® (netupitant & palonosetron)  Everolimus  Lorbrena (lorlatinib)  Sprycel (dasatinib)  Verzenio (abemaciclib)  Zelboraf (vemurafenib)

 Alecensa® (alectinib)  Exkivity™ (mobocertinib)  Lumakras™ (sotorasib)  Stivarga® (regorafenib)  Vizimpo® (dacomitinib)  Zolinza® (vorinostat)

RX PRESCRIPTION # ______® ® ® ® ® ®  Alunbrig (brigatinib)  Farydak (panobinostat)  Mekinist (trametinib)  Sutent (sunitinib malate)  Votrient (pazopanib)  Zydelig (idelalisib)  Tablets ® ® ® ® ™  Aromasin (exemestane)  Fotivda (tivozanib)  Mektovi (binimetinib)  Tafinlar (dabrafenib)  Welireg (belzutifan)  Zykadia™ (ceritinib)  Capsules

® ® ® ®  Bexarotene  Gleevec (imatinib mesylate)  Nerlynx (neratinib)  Talzenna (talazoparib)  Xalkori (crizotinib)  Zytiga® (abiraterone acetate)

 Bosulif® (bosutinib)  Hycamtin® (topotecan)  Nexavar® (sorafenib)  Tarceva® (erlotinib)  Xeloda® (capecitabine)  Other

™  Braftovi™ (encorafenib)  Ibrance® (palbociclib  Ninlaro® (ixazomib)  Targretin® (bexarotene)  Xermelo (telotristat ethyl)

®  Brukinsa™ (zanubrutinib)  Imatinib Mesylate  Nubeqa® (darolutamide)  Tasigna® (nilotinib)  Xospata (gilteritinib)

 Calquence® (acalabrutinib)  Imbruvica® (ibrutinib)  Odomzo® (sonidegib)  Tazverik® (tazemetostat) Refills

 Capecitabine  Inlyta® (axitinib)  Piqray® (alpelisib)  Temodar® (temozolomide)  Inqovi®  Copiktra® (duvelisib)  Pomalyst® (pomalidomide)  Temozolomide SIG: Directions Refills (decitabine and cedazuridine)

 Cotellic® (cobimetinib)  Inrebic® (fedratinib)  Promacta® (eltrombopag)  Thalomid® (thalidomide)

 Daurismo™ (glasdegib)  Kisqali® (ribociclib)  Retevmo™ (selpercatinib)  Tukysa™ (tucatinib)

 Deferasirox  Koselugo™ (selumetinib)  Revlimid® (lenalidomide)  Tykerb® (lapatinib)

 Erivedge® (vismodegib)  Lapatinib  Rezurock™ (belumosudil)  Ukoniq™ (umbralisib)

Diagnosis Information (For PA & Funding Support) Please include a complete list of medications and prior therapies with this order Primary Dx: Dx Date (needed for funding): ICD-10:

DX INFO. Secondary Dx: Dx Date (needed for funding): ICD-10:

Physician Information Prescriber name: Contact:

Email: Street: City:

State: Zip: Ph: Fax: NPI #:

Tax ID # (needed for funding): Prescriber Signature (required by law): Date:

REQUIRED PHYSICIAN INFO. Prescription will be filled with generic unless prescriber writes “DAW” (dispense as written) in the box

Shipping Instructions

INFO Ship to:  Physician’s Office  Patient’s Home  Other Date Required: SHIPPING

State law for MO/NY/OH/VA/VT allows only 1 medication per order form. Please use a new form for additional medications. ON-802 9.21

Pharmacy 877.662.6633 Fax 877.662.6355 Onco360.com