Current Specialty Drug Prescription(s) Information
Specialty Drug Name
*
If the specialty drug name is not listed, you do not need to complete this form.
Specialty Drug Name
ABIRATERONE ACETATE (GENERIC ZYTIGA)
ABRILADA
ACTEMRA
ADCIRCA
AFINITOR
AIMOVIG
AJOVY
ALECENSARO
ALITRETINOIN (GENERIC TOCTINO)
AMBRISENTAN (GENERIC VOLIBRIS)
AMGEVITA
APREMILAST (GENERIC OTEZLA)
AUBAGIO
AVONEX
BIMZELX
BOSULIF
BRENZYS
BYOOVIZ
CALQUENCE
CIMZIA
CINACALCET (GENERIC SENSIPAR)
COPAXONE
COSENTYX
DASATINIB (GENERIC SPRYCEL)
DIMETHYL FUMARATE (GENERIC TECFIDERA)
ELTROMBOPAG (GENERIC REVOLADE)
EMGALITY
ENBREL
ERELZI
ESBRIET
EVEROLIMUS (GENERIC AFINITOR)
EYLEA
FAMPYRA
FASENRA
FINGOLIMOD (GENERIC GILENYA)
FIRAZYR
FORTEO
GENOTROPIN
GILENYA
GLATECT
GLATIRAMER ACETATE (GENERIC COPAXONE)
GLEEVEC
HADLIMA
HANZEMA
HULIO
HUMATROPE
HUMIRA
HYRIMOZ
IDACIO
IMATINIB (GENERIC GLEEVEC)
IMBRUVICA
JAKAVI
KESIMPTA
KISQALI
LUCENTIS
LYNPARZA
MAVENCLAD
MEKINIST
NORDITROPIN
NPLATE
NUCALA
NUTROPIN
OCTREOTIDE (GENERIC SANDOSTATIN)
OLUMIANT
OMNITROPE
OPSUMIT
ORENCIA
OSNUVO
OTEZLA
PAZOPANIB (GENERIC VOTRIENT)
PIRFENIDONE (GENERIC ESBRIET)
PLEGRIDY
PRALUENT
PULMOZYME
QULIPTA
REBIF
REPATHA
REVATIO
REVOLADE
RILUTEK
RILUZOLE (GENERIC RILUTEK)
RINVOQ
ROZLYTREK
RUZURGI
SAIZEN
SANDOSTATIN
SANDOSTATIN LAR
SENSIPAR
SEROSTIM
SIMLANDI
SILDENAFIL R (GENERIC REVATIO)
SILIQ
SIMPONI
SKYRIZI
SOMATULINE
SPRYCEL
STELARA
SUTENT
TADALAFIL PAH (GENERIC ADCIRCA)
TAFINLAR
TALTZ
TASIGNA
TECFIDERA
TERIFLUNOMIDE (GENERIC AUBAGIO)
TERIPARATIDE (GENERIC FORTEO)
TOBI
TOBI PODHALER
TOFACITINIB (GENERIC XELJANZ)
TREMFYA
VASCEPA
VEMLIDY
VENCLEXTA
VERZENIO
VOLIBRIS
VOTRIENT
XELJANZ
XGEVA
XOLAIR
XOSPATA
YUFLYMA
ZAVESCA
ZEJULA
ZYTIGA
Second Specialty Drug Name (Optional)
Second Specialty Drug Name (Optional)
ABIRATERONE ACETATE (GENERIC ZYTIGA)
ABRILADA
ACTEMRA
ADCIRCA
AFINITOR
AIMOVIG
AJOVY
ALECENSARO
ALITRETINOIN (GENERIC TOCTINO)
AMBRISENTAN (GENERIC VOLIBRIS)
AMGEVITA
APREMILAST (GENERIC OTEZLA)
AUBAGIO
AVONEX
BIMZELX
BOSULIF
BRENZYS
BYOOVIZ
CALQUENCE
CIMZIA
CINACALCET (GENERIC SENSIPAR)
COPAXONE
COSENTYX
DASATINIB (GENERIC SPRYCEL)
DIMETHYL FUMARATE (GENERIC TECFIDERA)
ELTROMBOPAG (GENERIC REVOLADE)
EMGALITY
ENBREL
ERELZI
ESBRIET
EVEROLIMUS (GENERIC AFINITOR)
EYLEA
FAMPYRA
FASENRA
FINGOLIMOD (GENERIC GILENYA)
FIRAZYR
FORTEO
GENOTROPIN
GILENYA
GLATECT
GLATIRAMER ACETATE (GENERIC COPAXONE)
GLEEVEC
HADLIMA
HANZEMA
HULIO
HUMATROPE
HUMIRA
HYRIMOZ
IDACIO
IMATINIB (GENERIC GLEEVEC)
IMBRUVICA
JAKAVI
KESIMPTA
KISQALI
LUCENTIS
LYNPARZA
MAVENCLAD
MEKINIST
NORDITROPIN
NPLATE
NUCALA
NUTROPIN
OCTREOTIDE (GENERIC SANDOSTATIN)
OLUMIANT
OMNITROPE
OPSUMIT
ORENCIA
OSNUVO
OTEZLA
PAZOPANIB (GENERIC VOTRIENT)
PIRFENIDONE (GENERIC ESBRIET)
PLEGRIDY
PRALUENT
PULMOZYME
QULIPTA
REBIF
REPATHA
REVATIO
REVOLADE
RILUTEK
RILUZOLE (GENERIC RILUTEK)
RINVOQ
ROZLYTREK
RUZURGI
SAIZEN
SANDOSTATIN
SANDOSTATIN LAR
SENSIPAR
SEROSTIM
SIMLANDI
SILDENAFIL R (GENERIC REVATIO)
SILIQ
SIMPONI
SKYRIZI
SOMATULINE
SPRYCEL
STELARA
SUTENT
TADALAFIL PAH (GENERIC ADCIRCA)
TAFINLAR
TALTZ
TASIGNA
TECFIDERA
TERIFLUNOMIDE (GENERIC AUBAGIO)
TERIPARATIDE (GENERIC FORTEO)
TOBI
TOBI PODHALER
TOFACITINIB (GENERIC XELJANZ)
TREMFYA
VASCEPA
VEMLIDY
VENCLEXTA
VERZENIO
VOLIBRIS
VOTRIENT
XELJANZ
XGEVA
XOLAIR
XOSPATA
YUFLYMA
ZAVESCA
ZEJULA
ZYTIGA
Plan Member Information
Contact Information
The pharmacy team at MemberRx will contact you in advance of your prescription being transferred from your current pharmacy. For greater clarity, you will continue to receive your prescription through your current pharmacy until you are contacted by MemberRx.
Preferred Weekday Contact Time
Morning (9 a.m. - 12 p.m. ET)
Afternoon (12 p.m. - 4 p.m. ET)
Evening (4 p.m. - 7 p.m. ET)
Authorization, Terms and Conditions
Use the scroll tool below to carefully read the authorization, terms and conditions section of this form.
By providing this consent, I understand my personal information, or the personal information of my dependent child(ren) or spouse/partner if applicable, and details concerning any relevant health condition and medication history will be provided by my current pharmacy to MemberRx.
As parent, custodial parent, or legal guardian of my dependent child(ren) of minor or major age, I declare that I have full authority to consent to the collection, use, disclosure, and exchange of any information about him/her/them related to their prescription. I further declare that I am authorized by my spouse/partner to consent to the collection, use, disclosure, and exchange of information pertaining to my spouse/partner regarding their prescription.
I authorize MemberRx to collect, use, retain and disclose my personal information with my health care provider(s), pharmacy, and any other person or organization that may have relevant medical or health information about me, to fulfill my prescription needs and to verify information (“Purposes”). I also authorize MemberRx to contact me to collect clinical and logistics information, to store a patient's record in its Pharmacy Management computer system, and to request a prescription record transfer.
I further authorize OTIP/RAEO Benefits Inc. (“OTIP”), the Third Party Administrator for the group benefits plan, Manufacturer’s Life Insurance Company (“Manulife”), a Canadian insurer that provides group benefits administration and claims payment services for the benefits plan including but not limited to, adjudication and/or payment of prescription drug claims, Cubic Health Inc. (“Cubic”), the entity that runs the FACET Prior Authorization Program, and my current pharmacy to provide any information required by MemberRx to establish my file and dispense my prescription(s) for the Purposes.
By providing your email address, you acknowledge that email security cannot be guaranteed and agree to hold MemberRx harmless of all losses, expenses, or damages that could result by using electronic communications. It is your responsibility to inform MemberRx of a change in your email address or if you wish to withdraw your consent for email communications.
Consent
*
I understand and agree to the terms above.