You should not receive a "live vaccine" if you are treated with DUPIXENT. To reach your team, call toll-free 866.839.2162. The log information cookies do not collect any personal information.CountriesThe Site and its contents are intended for use by licensed physicians (and their staff) within the United States.This Web site may contain links to other Web sites. The long-term safety of DUPIXENT + TCS was assessed in an open-label extension study of 368 subjects 6 to 11 years of age with atopic dermatitis (Trial 7). February 2021, https://mothertobaby.org/ongoing-study/dupixent/. I understand that I can opt out from future text messages at any time by texting TEXTOUT to 39771 from my mobile phone, and that I can get help for text messages by texting TEXTHELP to 39771. Dupixent (dupilumab) 200 mg/1.14 mL* Dupixent (dupilumab) 300 mg/2 mL* 2 pre-filled syringes/pens per 28 days *Initiation of therapy: May approve two additional 200 mg/1.14 mL OR 300 mg/2 mL pre-filled syringes/pens in the first month of therapy for initiation dose for the indication of atopic dermatitis or asthma… DUPIXENT is an injection given under the skin (subcutaneous injection). DUPIXENT MyWay Enrollment Form: English … Please protect the confidentiality of your patients by not revealing or sharing login credentials. Yes, but I have not started taking DUPIXENT yet. Although Lash make a genuine effort to ensure the security of such information and the transactions conducted on the Site, including employing appropriate encryption technology, Lash can not guarantee the security of the information, nor can Lash guarantee that information you supply will not be intercepted while being transmitted via the Site. I acknowledge that by checking the Text Messaging Consent box, I expressly consent to receive text messages from or on behalf of the Program at the mobile telephone number(s) that I provide. It is not known whether DUPIXENT will harm your unborn baby. o w ith other asthma medicines for the maintenance treatment of moderate -to -severe asthma i n people aged 12 years and older whose asthma is not controlled with their current asthma medicines. Dupixent Insured patients may be eligible for the Dupixent Copay Card program and pay as little as $0 per month on their Dupixent prescriptions. Call your doctor for medical advice about side effects. If any provision of the Terms of Use is found to be invalid by any court having competent jurisdiction, the invalidity of such provision shall not affect the validity of the remaining provisions of the Terms and Conditions, which shall remain in full force and effect. APPROVAL CRITERIA I authorize the Alliance to contact me by mail, telephone, or email, with information about the Program, moderate-to-severe asthma and products, promotions, services and research studies, and to ask my opinion about such information and topics, including market research and disease-related surveys. FDA accepts Dupixent® (dupilumab) for review in children with moderate-to-severe asthma Submission supported by data demonstrating Dupixent significantly reduced severe asthma … The U.S. Food and Drug Administration has approved Dupixent ® (dupilumab) as an add-on maintenance therapy in patients with moderate-to-severe asthma aged 12 years and older with an eosinophilic phenotype or with oral corticosteroid-dependent asthma. © 2020 Sanofi and Regeneron Pharmaceuticals, Inc. All Rights Reserved. I may opt out of receiving Communications, individual support services offered by the Program, including the DUPIXENT MyWay Copay Card, or opt out of the Program entirely at any time by notifying a Program representative by telephone at 1-800-633-1610 or by sending a letter to Sanofi US Customer Service P.O. now approved as add-on maintenance treatment in patients (12+) with moderate-to-severe asthma with an eosinophilic phenotype or oral corticosteroid dependent asthma limitation of use: dupixent is not indicated for the relief of. I understand that my wireless service provider's message and data rates may apply. For assistance, call 1-844-DUPIXEN(T) (1-844-387-4936) … Learn about DUPIXENT® (dupilumab) for moderate-to-severe asthma treatment. Get information and tools delivered to your phone or mailbox for support to start and stay with treatment once your doctor has prescribed the medicine. 2.5 Preparation for Use of DUPIXENT 3 DOSAGE FORMS AND STR ENGTHS 4 CONTRAINDICATIONS 5 WARNINGS AND PRECAUT IONS 5.1 Hypersensitivity 5.2 Conjunctivitis and Keratitis 5.3 Eosinophilic Conditions 5.4 Acute Asthma Symptoms or Deteriorating Disease 5.5 Reduction of Corticosteroid Dosage 5.6 Patients with Co -morbid Asthma Paris and Tarrytown, NY--(BUSINESS WIRE)--The U.S. Food and Drug Administration (FDA) has accepted for review the supplemental Biologics License Application of Dupixent ® (dupilumab) as an add-on maintenance treatment in certain adults and adolescents (12 years of age and older) with moderate-to-severe asthma.Per the Prescription Drug User Fee Act, the target action date is October … Dupixent is injected under the skin, usually once every 2 to 4 weeks. Do not use if you are allergic to dupilumab or to any of the ingredients in DUPIXENT®. I understand that I do not have to enroll in the Program or receive the Communications, and that I can still receive DUPIXENT, as prescribed by my physician. In asthma, for patients 12 years and older, an improvement in lung function was seen in about 2 weeks, was significant at week 12 and was … My asthma doctor thought the sinus infection was related to my asthma so I had sinus surgery where they discovered many polyps. Fill out this form to see if you’re eligible for the DUPIXENT MyWay® Copay Card. DUPIXENT safely and effectively. Message and data rates may apply. I was put on Dupixent … Upload, post, email or otherwise transmit any material that contains software viruses or any other code, files or programs designed or known to disable, interrupt, or limit the functionality of any computer hardware, computer software, or telecommunications equipment or facilities. Enrollment Form Complete entire form and fax ALL 4 PAGES to DUPIXENT MyWay® at 1-844-387-9370. Please see accompanying full Prescribing Information including Patient Information. are pregnant or plan to become pregnant. Asthma . Such services include medication and adherence communications and support, medication dispensing support, coverage and financial assistance support, disease and medication education, injection training and other support services (the "Services"). DUP.21.01.0075 If return or destruction is infeasible, Lash agrees to extend all protections contained in this section of the Terms of Use to Lash's use and/or disclosure of any retained PHI, and to limit any further uses and/or disclosures to the purposes that make the return or destruction of the PHI infeasible. You are about to leave sanofi site for U.S. An adult with moderate-to-severe asthma that is not well controlled with current asthma medicines, A caregiver of someone with moderate-to-severe asthma that is not well controlled with current asthma medicines. Dupixent (dupilumab) 200 mg/1.14 mL* Dupixent (dupilumab) 300 mg/2 mL* 2 pre-filled syringes/pens per 28 days *Initiation of therapy: May approve two additional 200 mg/1.14 mL OR 300 mg/2 mL pre-filled syringes/pens in the first month of therapy for initiation dose for the indication of atopic dermatitis or asthma. Limitation of Use DUPIXENT is not indicated for the relief of acute bronchospasm or status asthmaticus . Among subjects who entered this study, 110 (30%) had moderate and 72 (20%) had severe atopic dermatitis at the time of enrollment in Trial 7. Seek medical attention if your breathing problems get worse quickly, or if you think your asthma medications are not working as well. I also understand that the Services may be revised, changed, or terminated at any time. This site might not comply with the regulatory requirements of US, Your friend has shared this page about WhiteSite. Box 5925 Mailstop 55A-220A Bridgewater, NJ 08807. DUPIXENT® is an add-on maintenance therapy for moderate-to-severe asthma patients aged 12+ with an eosinophilic phenotype or with oral corticosteroid dependent asthma. DUPIXENT… Dupixent® 200mg PFS w/Shield Asthma Atopic Dermatitis Load: Inject 400mg subcutaneously (2-200mg syringes in different injection sites) on Day 1, then 200mg on Day 15, ... Fasenra® Fax completed Fasenra Access 360TM Enrollment Form to Kroger Specialty Pharmacy at 844.306.0200 CVS Caremark Specialty Programs 2969 Mapunapuna Place Honolulu, HI 96819 Phone: 1-808-254-4414 Fax: 1-866-237- 5512 www.caremark.com Only asthma biologic that offers patient self-administration at home. See full prescribing information for DUPIXENT. website and/or database producer. Yes, but they have not started taking DUPIXENT yet, Commercial health insurance plan purchased through an employer or purchased personally and does not include the insurance types listed below, Government-sponsored programs (e.g. DUPIXENT is a prescription medicine used with other asthma medicines for the maintenance treatment of moderate-to-severe eosinophilic or oral steroid dependent asthma in people aged 12 years and older whose asthma is not controlled with their current asthma medicines. I also understand that the Services may be revised, changed, or terminated at any time. These are not all the possible side effects of DUPIXENT. Dupixent ® (dupilumab) significantly reduced severe asthma attacks in children and is the only biologic to demonstrate improvement in children’s lung function in a randomized Phase 3 trial. It is not known if DUPIXENT is safe and effective in children with asthma under 12 years of age. I may opt out of receiving Communications, individual support services offered by the Program or opt out of the Program entirely at any time by notifying a Program representative by telephone at 1-800-633-1610 or by sending a letter to Sanofi US Customer Service P.O. 1 PATIENT INFORMATION (Complete or include demographic sheet) There is no agency, partnership or joint venture relationship between any user and Lash arising solely through the use of the Site. i understand that dupixent myway may revise, change, or terminate any program services at any time without notice to me. Click on document links below to download forms, DUPIXENT MyWay Respiratory Enrollment Form, DUPIXENT MyWay Dermatology Enrollment Form, https://mothertobaby.org/ongoing-study/dupixent/. Dupixent is currently approved as an add-on treatment for patients with uncontrolled moderate-to-severe asthma aged 12 and older with elevated eosinophils or oral corticosteroid dependent asthma. DUPIXENT MyWay Respiratory Enrollment Form DUPIXENT MyWay Dermatology Enrollment Form DUPIXENT MyWay Copay Reimbursement Form ... Asthma: DUPIXENT is indicated as an add-on maintenance treatment in patients with moderate-to-severe asthma aged 12 years and older with an eosinophilic phenotype or with oral corticosteroid dependent asthma. The Terms of Use are binding upon your successors, assigns, heirs and executors. FDA Accepts Dupixent® (dupilumab) for Review in Children with Moderate-to-severe Asthma PR Newswire TARRYTOWN, N.Y. and PARIS, March 4, 2021 TARRYTOWN, N.Y. Marketing communications will not be sent to patients under the age of 18. Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the EPHI that Lash creates, receives, maintains, or transmits on your behalf; Ensure that any agent, including a subcontractor, to whom Lash provides such EPHI, agrees to implement reasonable and appropriate safeguards to protect it; Report any Security Incident of which Lash become aware; provided, that trivial attempts to penetrate Lash's systems that occur on a daily basis such as scans, "pings" or other unsuccessful attempts to penetrate computer networks or systems maintained by Lash, will not be reported; and. DUPIXENT helps prevent severe asthma attacks (exacerbations) and can improve your breathing. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088. Dupixent is not a rescue medicine for asthma attacks. I understand that my consent is not required as a condition of purchasing any goods or services from Regeneron Pharmaceuticals, Inc. or Sanofi. I understand that members of the Alliance may share identifiable health information with one another in order to de-identify it for these purposes and as needed to perform the Services or to send the communications listed above (the "Communications"). Patient Refills: 888-777-5547 Prescriber questions or help: 855-460-7928 Fax: 888-777-5645 All other inquiries: 888-777-5547 Visit the Dupixent website or call 1-844-387-4936 to see if you are eligible for the savings program. Limitation of Use: Not for the relief of acute bronchospasm or status asthmaticus. Access to personally identifiable information is limited only to those Lash employees or representatives, and other third-party vendors and partners, who have a business need to know, all of whom are required to keep your information confidential.Except with respect to PHI, any communication or material that you transmit to, or post on, the Site by electronic mail or otherwise, including any data, questions, comments, suggestions, or the like, is, and will be treated as, nonconfidential and nonproprietary information, and Lash shall not have any obligation of any kind with respect to such information. Lash and any of our affiliates may use such information for any purpose whatsoever, including, but not limited to, reproduction, disclosure, transmission, publication, broadcast, and further posting. You acknowledge this and that system failures may limit your ability to use the Site. Limitation of Use: DUPIXENT … Do not try to inject DUPIXENT until you have been shown the right way by your healthcare provider. Asthma Enrollment Form Medications A-E (Cinqair®, Dupixent®) Six Simple Steps to Submitting a Referral 1 PATIENT INFORMATION (Complete or include demographic sheet) Patient Name: … not use or disclose PHI other than as permitted or required by these Terms of Use or as otherwise required or permitted by law; use appropriate safeguards to prevent use or disclosure of PHI other than as provided for by these Terms of Use; report in writing to you any use or disclosure of PHI not provided for by these Terms of Use of which Lash's management becomes aware within ten (10) business days of Lash's knowledge of an unauthorized use or disclosure; mitigate, to the extent practicable, any harmful effect that is known to Lash of a use or disclosure of PHI by Lash in violation of the requirements of these Terms of Use; require all of its subcontractors and agents that receive or use, or have access to, PHI, to agree, in writing, to essentially the same restrictions and conditions on the use and/or disclosure of PHI that apply to Lash pursuant to this section of the Terms of Use; make available PHI necessary for you to respond to individuals' requests for access to PHI about them in the event that the PHI in Lash's possession constitutes a Designated Record Set. Actual results may differ from the forward-looking information.MiscellaneousThe Terms of Use constitute the entire agreement between you and Lash relating to the Site. The section titles of the Terms of Use are merely for convenience and will not have any effect on the substantive meaning of this Agreement.IMPORTANT SAFETY INFORMATIONThe Alpha drug is not right for you if: © 2020 Sanofi and Regeneron Asthma Enrollment Form Medications A-E (Cinqair®, Dupixent®) Six Simple Steps to Submitting a Referral 1 PATIENT INFORMATION (Complete or include demographic sheet) Patient Name: _____Address: _____City, State, ZIP: _____ You agree to assume all risk and liability arising from your use of the Site, including the risk posed by any breach in the security of communications and transactions you conduct through the Site.Lash may have access to PHI received from you and other authorized users of the Site only if that information has been de-identified in a manner consistent with HIPAA's applicable privacy and security provisions or if such access is otherwise permitted or required by law. the patient designated below to be given the therapy (Dupixent injections) over an extended period of time and at specified intervals, as prescribed by Princeton Allergy and Asthma. Please note: By clicking on this link, you will be leaving this Sanofi-hosted US website and going to another, entirely independent website. Tell your healthcare provider if you have any side effect that bothers you or that does not go away. DUPIXENT® is a prescription medicine used as an add-on maintenance treatment for people 12 and up who have uncontrolled moderate-to-severe eosinophilic or oral steroid dependent asthma. DUPIXENT ® (dupilumab) injection, for subcutaneous use Initial U.S. Approval: 2017 . Lash shall provide you with the PHI within a reasonable time from the date of the request; make available PHI for amendment within a reasonable time of receipt of a written request and incorporate any amendments to the PHI within ten (10) business days in accordance with the Privacy Rule of HIPAA in the event that the PHI in Lash's possession constitutes a Designated Record Set; provide you with an accounting of disclosures for individual in the form required by 45 C.F.R. 164.528 within a reasonable time of your request; make its internal practices, books and records relating to the use and disclosure of PHI available to you and the Secretary of HHS or designee for purposes of determining your compliance with the Privacy Rule; and. Fill out, securely sign, print or email your Dupixent MyWay Program Enrollment Form instantly with SignNow. to provide you with additional information about products or services (of ours and of others) that may be of interest to you. In children 12 years of age and older, it is recommended that DUPIXENT be administered by or under supervision of an adult. DUPIXENT (DUPILUMAB) (NON-PREFERRED) PRIOR AUTHORIZATION FORM (form effective 1/5/21) Fax to PerformRx. I further hereby give authorization and consent for treatment, from Princeton Allergy and Asthma and the staff, of any reactions that may occur as a result of the I further authorize the Alliance to de-identify my health information and use it in performing research, education, business analytics, marketing studies or for other commercial purposes. Use DUPIXENT exactly as prescribed. Be sure to check your inbox. “Type 2 inflammation is responsible for many of the hallmark symptoms of asthma – and Dupixent is the first and only treatment approved for patients in the European Union with severe asthma characterized by multiple biomarkers of type 2 inflammation,” said George D. Yancopoulos, M.D., Ph.D., President and Chief Scientific Officer at Regeneron. I am interested in receiving DUPIXENT information and resources. It is not known whether DUPIXENT passes into your breast milk. Takeda Signs an Exclusive License Agreement with Ovid for Soticlestat to Treat Dravet Syndrome and Lennox-Gastaut Syndrome Asthma Enrollment Form Medications A-E (Cinqair®, Dupixent®) Fax Referral To: 1-800-323-2445 Phone: 1-800-237-2767 Email Referral To: [email protected] Six Simple Steps to Submitting a Referral 1 PATIENT INFORMATION (Complete or include demographic sheet) There is a pregnancy exposure registry for women who take DUPIXENT during pregnancy to collect information about the health of you and your baby. This Site also uses cookies when you visit to help recognize and track non-personal information, including your internet service provider. Asma: DUPIXENT® (dupilumab) está indicado como tratamiento de mantenimiento adicional en pacientes con asma de moderada a grave de 12 años de edad o más con un fenotipo eosinofílico o con asma dependiente de corticosteroides orales. GET A DUPIXENT MyWay ENROLLMENT FORM. To reach your team, call toll-free 808.650.6488. Important Safety Information and Indication. To enroll in DUPIXENT MyWay, your patients can call 1-844-DUPIXEN(T) (1-844-387-4936) or download and fill out an enrollment form with your assistance. With regard to PHI, the Site will employ appropriate administrative, physical, technical, and managerial procedures to safeguard and secure the information collected, consistent with industry practices and the sensitivity of the information provided. I confirm that I am the subscriber for the mobile telephone number(s) provided, and I agree to notify Sanofi promptly if any of my number(s) change in the future. In rare cases, patients taking an asthma medicine may develop an inflammation of blood vessels or lungs. to comply with any applicable law or regulation, court order or other legal process. and version. Data in children aged 6-11 further suggest Dupixent has potential to be best-in-class treatment option Dupixent significantly reduced severe asthma attacks by up to 65% over one year compared to placebo 2 DOSAGE AND ADMINISTRATION Dupixent Myway Form. for content, accuracy or completeness. To enroll in DUPIXENT MyWay, your patients can call 1-844-DUPIXEN(T) (1-844-387-4936) or download and fill out the following forms with your assistance. Sanofi US does not review the information
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