Revlimid Patient Physician Agreement Form

By October 5, 2021 No Comments

To register and contact your patients, obtain more information and download forms related to the REVLIMID REMS program® please visit For each of your subsequent REVLIMID prescriptions, you must follow a similar process. Detailed information on the requirements of the REVLIMID REMS program is available in or in the patient guide for the REVLIMID REMS program. Revlimid may be available free of charge for qualified patients who are uninsured or underinsured.† Email us at or fax to 1-800-822-2496. Possible birth defects (deformed babies) or the death of an unborn baby. Women who are pregnant or planning to become pregnant should not take REVLIMID. Depending on your patient`s insurance situation, there are programs and organizations that can help pay REVLIMID. For patients who can`t afford their medications (including patients with Medicare, Medicaid, or any other publicly subsidized insurance), independent third-party organizations can help. Your doctor will advise you on why and how you and your partner should avoid pregnancy. Your doctor will also inform you not to share the medicine, not to donate blood or semen, and the proper use of contraceptives. You must be instructed not to process or open REVLIMID® (lenalidomide) capsules To track your medicine, key data and information, use this table and schedule.

To avoid embryo-tale exposure, REVLIMID is only available through a limited distribution program called REVLIMID Risk Evaluation and Mitigation Strategy (REMS) ®. The REVLIMID REMS® program requires prescribing physicians and pharmacies to be certified and for patients to enroll and meet all program requirements. For eligible patients with commercial or private insurance (including health scholarships)*, the liability for the REVLIMID supplement is reduced to $25 (subject to the annual cap). Whether you`re a patient, caregiver, or family member, download a REVLIMID Conversation starter to learn how to talk about multiple myeloma with your doctor and with each other. You and your doctor will then fill out the patient-doctor agreement® form (lenalidomide) and submit more on current tests and record your progress and adverse reactions during your treatment. The special pharmacy will contact you to advise you on the serious risks and safe conditions of use of REVLIMID before receiving your prescription. You also coordinate the delivery of REVLIMID To avoid serious risks to unborn babies, REVLIMID is only available through a limited distribution program called REVLIMID Risk Evaluation and Mitigation Strategy (REMS). You and your healthcare provider will each complete a survey.

Visit or call 1-888-423-5436 and press 1 to participate in your survey ‖Celgene offers moderation service and does not provide any medical contribution to prior authorization or objection. §Celgene cannot offer insurance advice or make insurance decisions. Before prescribing REVLIMID, you must participate in the REVLIMID REMS program. There are specific requirements for both men and women in the program. Our specialists are at your disposal to assist you in each of the following steps in the insurance authorization process for REVLIMID.. . . .