<> endobj The AZ&Me Prescription Savings program is designed to help qualifying patients, including those who receive their medications through participating healthcare facilities. 163 0 obj <> When using the enrollment portal, at the completion of the enrollment … The specific … Specialty Distributors (SD): The IMFINZI … Restricted … Dosing for IMFINZI is weight-based so the dose will vary by patient, and may be provided through a combination of vial sizes. from application/x-indesign to application/pdf Select Safety Information. / <>stream false Download IMFINZI Enrollment Forms and Resources. endobj Then, fill in the required prescription and enrollment information and fax it to us at the number printed on the form. Important Safety Information. endstream endobj startxref 2 5 6 3 AstraZeneca Access 360™ Enrollment Form Please complete form, sign, and fax all pages to 1-844-329-2360. application/pdf Imfinzi. 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 … 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 … 2018-02-15T12:05:50.000-05:00 There are no contraindications for IMFINZI ® (durvalumab).. Immune-Mediated Adverse Reactions. [null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null 1069 0 R 1067 0 R 1071 0 R 1073 0 R 1074 0 R 1075 0 R 1076 0 R 1077 0 R 1078 0 R 1079 0 R 1080 0 R 1081 0 R 1082 0 R 1083 0 R 1084 0 R 1085 0 R 1086 0 R 1087 0 R 1088 0 R 263 0 R 1005 0 R 1007 0 R 1005 0 R 1005 0 R 1006 0 R 1064 0 R 1065 0 R 1061 0 R 1062 0 R 1063 0 R 1044 0 R 1045 0 R 1046 0 R 1047 0 R 1048 0 R 1049 0 R 1050 0 R 1051 0 R 1052 0 R 1053 0 R 1054 0 R 1055 0 R 1056 0 R 1057 0 R 1058 0 R 1059 0 R 1060 0 R 1042 0 R 1043 0 R 1035 0 R 1036 0 R 1037 0 R 1032 0 R 1033 0 R 1034 0 R 1029 0 R 1030 0 R 1031 0 R 1026 0 R 1027 0 R 1028 0 R 1019 0 R 1020 0 R 1021 0 R 1016 0 R 1017 0 R 1018 0 R 1011 0 R 1012 0 R 1013 0 R 1014 0 R 1015 0 R 1090 0 R 963 0 R 964 0 R 1004 0 R 972 0 R 973 0 R 974 0 R 975 0 R 976 0 R 977 0 R 978 0 R 979 0 R 980 0 R 981 0 R 982 0 R 983 0 R 984 0 R 985 0 R 986 0 R 987 0 R 988 0 R 989 0 R 990 0 R 991 0 R 992 0 R 993 0 R 994 0 R 995 0 R 996 0 R 997 0 R 998 0 R 999 0 R 1000 0 R 1001 0 R 1002 0 R 1003 0 R 967 0 R 967 0 R 967 0 R 971 0 R 967 0 R 968 0 R 968 0 R 968 0 R 969 0 R 969 0 R 969 0 R 970 0 R 969 0 R] PD-L1 is a protein that’s overexpressed by cancer … xmp.id:DE0AF0EB29206811822AB634F0DC0EC0 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, … 1190 0 obj 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). %PDF-1.7 %���� 2017-11-01T09:48:13.000-06:00 endobj 179 0 obj <> endobj <>/A1<>/A10<>/A11<>/A12<>/A2<>/A4<>/A5<>/A7<>/A8<>/A9<>/Pa0<>/Pa1<>/Pa10<>/Pa11<>/Pa12<>/Pa2<>/Pa3<>/Pa4<>/Pa7<>>> endobj endobj 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.. 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 administered via IV in the hospital and does not come in a pill form. 2018-02-15T11:05:50.000-06:00 false Page 4 | IMFINZI® (durvalumab) Prior Auth Criteria Proprietary Information. %%EOF 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 … proof:pdf <. xmp.did:B71D21B42620681188C6FB56A0F3D044 uuid:f75bf3a8-44aa-4a0d-9047-0c1da5ca42a7 <> Adobe PDF Library 10.0.1 endobj IMFINZI Enrollment Form A multi-page enrollment form to capture necessary patient, provider, and prescription information to start a new request for support. <>/Metadata 1247 0 R/Outlines 154 0 R/Pages 1187 0 R/StructTreeRoot 155 0 R/Type/Catalog/ViewerPreferences<>>> 397865 6 endobj endobj Imfinzi offers may be in the form of a printable coupon, rebate, savings card, trial offer, or free samples. 2018-07-31T09:57:12.155-05:00 3 Fax Referral Form … If approved, Imfinzi … This administration takes about 60 minutes per session, and these sessions occur every two to four weeks. Adobe PDF Library 10.0.1 endobj xmp.iid:DBC29F2F2720681188C6FB56A0F3D044 164 0 obj GET STARTED. Surgery was discussed … endobj endobj 161 0 obj h�b``�e``Ue`g`�Z b�/P������ PŚ{EO��R[��u��W��W���ww�t��WN�. Imfinzi … Important immune-mediated adverse reactions listed under Warnings … There are no contraindications for IMFINZI ® (durvalumab).. Immune-Mediated Adverse Reactions. 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null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null 166 0 R 167 0 R 168 0 R 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241 0 R 242 0 R 243 0 R 244 0 R] endobj A multi-page enrollment form to capture necessary patient, provider, and prescription information to start a new request for support. 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Hi All! <> 167 0 obj 168 0 obj Imfinzi with NDC 0310-4500 is a a human prescription drug product labeled by Astrazeneca Pharmaceuticals Lp. DOWNLOAD IN ENGLISH DOWNLOAD IN SPANISH Click here to fill out the form online. 444 0 obj <>stream 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. Important immune-mediated adverse reactions listed under Warnings … Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials [see Clinical Studies (14.1)]. The generic name of Imfinzi is durvalumab. 170 0 obj xmp.did:11060ec6-5e9f-4a46-a268-e4815d3e6ec8 Referral forms To begin the referral process, find the referral form by specialty condition and product name in the list below. <> Adobe InDesign CS6 (Macintosh)
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