Sebela patient assistance program lotronex alosetron hcl 0. A patient followup survey program for lotronex alosetron. Your prescription must have a sticker affixed to it in order for your pharmacy to dispense you a supply of this medicine. A patient is defined as those persons for whom the physician shall provide. The complete text of the medication guide is printed at the end of this document. Lotronex, the patient must read and sign the patient physician agreement see precautions. This resource includes two sample patient agreement forms that can be used with patients who are beginning longterm treatment with opioid analgesics or other controlled substances.
Sign a patientphysician agreement with your doctor. Management of irritable bowel syndrome american family. Prior authorization request form for lotronex alosetron. Alosetron hydrochloride is a potent, selective serotonin 3 5ht 3 receptor antagonist indicated for the treatment of women with chronic lasting 6 months, severe ibsd and no anatomic or biochemical abnormalities of the gi tract who have not responded adequately to conventional therapy. These documents contain statements to help ensure patients understand their role and. A medication guide for lotronex must be given to the patient each time lotronex is dispensed as required by law. Have both the patient and physician signed the patient physician agreement. We do our best to stay on top of our patient accounts, sending out statements or refunds where they are necessary. Apr 11, 2019 what other drugs will affect alosetron lotronex. Understand that lotronex has serious risks for some people. The patientphysician agreement should be signed, with the original in the patients chart and a copy to the patient, prior to initiatingtherapy. Lotronex, alosetron dosing, indications, interactions. Read and follow the directions in this medication guide.
At baseline, over 90% of patients reported signing a physicianpatient agreement ppa, having discussions with their physician about using lotronex, and having read the medication guide. Inability to comply with the patientphysician agreement for lotronex. Rems enrollmentagreement form name patient agreement prescriber. I understand my signature indicates that i am in agreement with the previously outlined patient responsibilities. Lotronex alosetron hydrochloride is one of the new breed of medications for ibs, and was introduced in the united states in 2000. No telephone, facsimile, or computerized prescriptions are permitted with this program.
Read this medication guide carefully before you sign the patientphysician agreement. If you see other doctors about your ibs or possible side effects from lotronexalosetron hydrochloride, tell the doctor who prescribed lotronexalosetron hydrochloride. Clinical efficacy of serotonin agonists and antagonists. By the signature of the authorized representative below, hereinafter referred to as the transferring facility, hereby affirms andor agrees that the following conditions are met. Read and complete the patientphysician agreement form provided by your doctor. Medication summary lotronex is indicated for the treatment of irritable bowel syndrome ibs in female. Lotronex rems program patient education sheet fda required lotronex alosetron hydrochloride safety information what is lotronex alosetron hydrochloride. It is important that you follow all these instructions, exactly. This includes requests for benefit coverage beyond pl an specifications. Inability to comply with the patient physician agreement for lotronex. Contains confidential patient information lotronex. I hereby release the rehabgym of any responsibility for the loss or theft of any personal items left in any section of the rehabgym. Also, be sure to get a medication guide from your pharmacist, and then read it carefully.
Summary background alosetron was reintroduced for treatment of irritable bowel syndrome with a risk management programme in november 2002. Lotronex should be discontinued immediately in patients who develop constipation or symptoms of ischemic colitis. Only physicians who have enrolled in the prometheus prescribing program for. Has the patient received and completed the lotronex medication guide. Read this medication guide carefully before you sign the patient physician agreement. Sample patient agreement forms national institute on drug. Brenner, jd the doctorpatient relation is inherently contractual.
I agree to adhere to the payment policy outlined by this office. On 9 february 2000 alosetron marketed as lotronex by glaxosmithkline, a type 3 serotonin 5ht 3 receptor antagonist, was approved by the us food and drug administration fda for the treatment of patients with irritable bowel syndrome, a benign though unpleasant disorder that affects one in five adults in the industrialised world. Sebela patient assistance program po box 219, gloucester. Lotronex alosetron hydrochloride is a prescription medicine only for women with severe irritable bowel syndrome. Patientphysician partnering to improve chronic disease care.
I understand that if i violate this agreement, i may be subject to termination of my primary physicianpatient relationship, as well as, physicians of. At baseline, over 90% of patients reported signing a physician patient agreement ppa, having discussions with their physician about using lotronex, and having read the medication guide. Is the physician enrolled in the lotronex prescribing program. Risk is increased in patients who are elderly, debilitated, or taking medications that decrease bowel motility the incidence of serious complications of constipation was approximately 0. Sep 14, 2002 on 9 february 2000 alosetron marketed as lotronex by glaxosmithkline, a type 3 serotonin 5ht 3 receptor antagonist, was approved by the us food and drug administration fda for the treatment of patients with irritable bowel syndrome, a benign though unpleasant disorder that affects one in five adults in the industrialised world. Lotronex fda prescribing information, side effects and uses. You can tell if your ibs is severe if at least 1 of these is true. Patient medication agreement for painkillers, anxiety medication, stimulants, and all controlled substances. The patient portal is designated to enhance patientphysician communications. By providing your fax you are giving us permission to contact you in this way. Optimizing outcomes with alosetron hydrochloride in severe. Alosetron for irritable bowel syndrome pubmed central pmc. The patient portal is designed to enhance patient physician communication. This form describes patient first s treatment and payment policies and covers such important topics as.
Have both the patient and physician signed the patientphysician agreement. This education sheet only discusses the most serious risk information of lotronex alosetron hydrochloride. Its use is under restricted conditions that include completion of a signed patientphysician agreement and prescription only by physicians enrolled in the prescribing program for lotronex. Understanding of the patient medication guide and consent to participate in the patient physician agreement the original prescription will be approved for a maximum duration of one month. Electronic prescriptions are now allowed patients are no longer required to complete and submit a patient acknowledgment form. My signature below signifies that i have read and understand this patient agreement for mark richey, md, pc to provide me medical services. If you see other doctors about your ibs or possible side effects from lotronex alosetron hydrochloride, tell the doctor who prescribed lotronex alosetron hydrochloride. You are being prescribed a medicine that has many risks. Lotronexalosetron hydrochloride pharmacies are no longer required to only dispense lotronexalosetron hydrochloride for a paper prescription with an affixed prescribing program sticker. This education sheet only discusses the most serious risk information of lotronexalosetron hydrochloride. If the patient has received previous lotronex therapy, has there been improvement of.
Lotronex may be dispensed only on presentation of a prescription for lotronex with a sticker for the prescribing program for lotronex attached. Early on, we formed a physicianled team to develop a patientphysician partnership agreement download the agreement here in pdf format and to define the patient care goals, based on evidenced. The patient physician agreement should be signed, with the original in the patient s chart and a copy to the patient, prior to. Lotronex, the patient must read and sign the patientphysician agreement see precautions. Your doctor will ask you to sign a patient physician agreement after you have read the medication guide for the first time. Some drugs can affect your blood levels of other drugs you take, which may increase side effects or make the medications less effective. Regarding patient balances and credits, we ask for prompt payment of any outstanding balances that are due, yet we are also eager to refund any money or credit due to the patient. Gebhart, in practical management of pain fifth edition, 2014.
The medicine also has special laws that the doctor and patient must follow. Discontinue if inadequate control after 4 weeks of q12hr dosing. Your doctor will ask you to sign a patientphysician agreement after you have read the medication guide for the first time. Physicianpatient private contract agreement even though you, the patient, and lesley james md, the physician, are entering into a private agreement outside of medicare, medicare requires your signed agreement to the following terms medicare has specified, before your first appointment. Read the medication guide before starting alosetron for the first time and each time you refill your alosetron prescription. The patient portal is designated to enhance patient physician communications. Your patients pharmacy benefit program is administered by unitedhealthcare, which uses optumrx for certain pharmacy benefit services. The approved snda for lotronex includes a risk management program to ensure patients and physicians are fully informed of risks and possible benefits of lotronex. I understand that if i violate this agreement, i may be subject to termination of my primary physician patient relationship, as well as, physicians of other hillcrest family health center facilities. Your consent to receive medical treatment from patient first and your other rights and responsibilities. Read and complete the patient physician agreement form provided by your doctor. Recommended starting dosage was 1 mgday for 4 weeks.
Patient has any contraindications to the use of alosetron. Check box to have prescription sent to the physicians address listed above. Fda required rems safety information lotronex rems. Understanding of the patient medication guide and consent to participate in the patientphysician agreement the original prescription will be approved for a maximum duration of one month. Before receiving the initial prescription of lotronex, the patient must read and sign the patient physician agreement for lotronex. Lotronex is a medicine only for some women with severe irritable bowel syndrome ibs whose main problem is diarrhea. Lotronex alosetron hydrochloride tablets initial u.
Patient portal user agreement we are pleased to provide a patient portal in partnership with our electronic medical records provider for the exclusive use of established patients. Sign a patient physician agreement with your doctor. I agree to keep and be on time to all my scheduled appointments. Patients should read the medication guide before starting alosetron and each time they re. Pharmacists were required to dispense a medication guide and were asked to check. The 5ht 3 antagonist alosetron has been used successfully in patients with functional bowel disease characterized by abdominal pain and diarrhea. Prior authorization approval criteria fallon health. This list may help guide you and your doctor in selecting an appropriate medication for you. Sometimes it is not safe to use certain medications at the same time. Care choices medication guide may 2020 please consider talking to your doctor about prescribing one of the formulary medications that are indicated as covered under your plan. Sebela patient assistance program po box 219, gloucester, ma. Prescribing program which utilizes special program stickers that the enrolled physician will affix to all prescriptions for lotronex. Contains confidential patient information hoosier healthwise.
Contains confidential patient information lotronex alosetron. Discontinue immediately if symptoms of constipation or ischemic colitis occurs. Before prescribing revlimid, your healthcare provider will explain the revlimid rems program to you and have you sign the patientphysician agreement form. Answer all questions the patient may have about lotronex. Sample patient agreement forms national institute on drug abuse. Rems enrollment agreement form name patient agreement prescriber. Discontinue lotronex immediately if constipation occurs. Physicians should instruct patients to immediately report constipation or symptoms of ischemic colitis. Before you begin taking revlimid, you must read and agree to all of the instructions in the revlimid rems program.
The prescribing program for lotronex was implemented to help reduce risks of serious gastrointestinal adverse reactions. Lotronex is a selective 5ht3 receptor antagonist, which means that it works on neurons in the digestive tract, blocking the action of serotonin in the gut and decreasing motility. Before receiving the initial prescription of lotronex, the patient must read and sign the patientphysician agreement for lotronex. Results indicate a high rate of compliance with respect to appropriate patient prescribing, patients signing the ppa, and reading. It is understood that any item may be placed in the hands of a person at. By providing your email you are giving us permission to contact you in this way. We do not provide emergency services for users of our site. Patient statement of agreement this patient agreement and the terms within it are effective for three 3 years from the date of my signature or until the agreement is revised. All users must be established by a previous office visit.