Your doctor will ask you to sign a patient physician agreement after you have read the medication guide for the first time. Discontinue if inadequate control after 4 weeks of q12hr dosing. Read and complete the patientphysician agreement form provided by your doctor. Have both the patient and physician signed the patient physician agreement. Contains confidential patient information hoosier healthwise. These documents contain statements to help ensure patients understand their role and. Sometimes it is not safe to use certain medications at the same time. Lotronex fda prescribing information, side effects and uses. Prior authorization approval criteria fallon health. Prior authorization request form for lotronex alosetron.
Optimizing outcomes with alosetron hydrochloride in severe. Is the physician enrolled in the lotronex prescribing program. Read this medication guide carefully before you sign the patient physician agreement. 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. Lotronex rems program patient education sheet fda required lotronex alosetron hydrochloride safety information what is lotronex alosetron hydrochloride. The complete text of the medication guide is printed at the end of this document. Gebhart, in practical management of pain fifth edition, 2014. Apr 11, 2019 what other drugs will affect alosetron lotronex. Lotronex alosetron hydrochloride tablets initial u. Before receiving the initial prescription of lotronex, the patient must read and sign the patient physician agreement for lotronex. Sebela patient assistance program lotronex alosetron hcl 0. We do our best to stay on top of our patient accounts, sending out statements or refunds where they are necessary. Your prescription must have a sticker affixed to it in order for your pharmacy to dispense you a supply of this medicine. 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.
Inability to comply with the patientphysician agreement for lotronex. 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. This includes requests for benefit coverage beyond pl an specifications. Results indicate a high rate of compliance with respect to appropriate patient prescribing, patients signing the ppa, and reading. All users must be established by a previous office visit. Medication summary lotronex is indicated for the treatment of irritable bowel syndrome ibs in female. Check box to have prescription sent to the physicians address listed above. My signature below signifies that i have read and understand this patient agreement for mark richey, md, pc to provide me medical services. As a participant in buprenorphine treatment for opioid misuse and dependence, i freely and voluntarily agree to accept this treatment agreement as follows. Rems enrollmentagreement form name patient agreement prescriber. Sign a patientphysician agreement with your doctor. Lotronex should be discontinued immediately in patients who develop constipation or symptoms of ischemic colitis.
Read the medication guide before starting alosetron for the first time and each time you refill your alosetron prescription. 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. The patient portal is designated to enhance patient physician communications. Prescribing program which utilizes special program stickers that the enrolled physician will affix to all prescriptions for lotronex. 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. Sample patient agreement forms national institute on drug. The patient physician agreement should be signed, with the original in the patient s chart and a copy to the patient, prior to. Lotronex alosetron hydrochloride is one of the new breed of medications for ibs, and was introduced in the united states in 2000. Your patients pharmacy benefit program is administered by unitedhealthcare, which uses optumrx for certain pharmacy benefit services. Rems enrollment agreement form name patient agreement prescriber. 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.
If the patient has received previous lotronex therapy, has there been improvement of. 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. 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. Read and follow the directions in this medication guide. The patient portal is designed to enhance patient physician communication.
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. Sample patient agreement forms national institute on drug abuse. Patientphysician partnering to improve chronic disease care. Before receiving the initial prescription of lotronex, the patient must read and sign the patientphysician agreement for lotronex. Brenner, jd the doctorpatient relation is inherently contractual.
Discontinue immediately if symptoms of constipation or ischemic colitis occurs. Some drugs can affect your blood levels of other drugs you take, which may increase side effects or make the medications less effective. Patient medication agreement for painkillers, anxiety medication, stimulants, and all controlled substances. The 5ht 3 antagonist alosetron has been used successfully in patients with functional bowel disease characterized by abdominal pain and diarrhea. The prescribing program for lotronex was implemented to help reduce risks of serious gastrointestinal adverse reactions. No telephone, facsimile, or computerized prescriptions are permitted with this program. 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. Electronic prescriptions are now allowed patients are no longer required to complete and submit a patient acknowledgment form. If you see other doctors about your ibs or possible side effects from lotronex alosetron hydrochloride, tell the doctor who prescribed lotronex alosetron hydrochloride. 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.
I agree to keep and be on time to all my scheduled appointments. The patientphysician agreement should be signed, with the original in the patients chart and a copy to the patient, prior to initiatingtherapy. You are being prescribed a medicine that has many risks. 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.
I hereby release the rehabgym of any responsibility for the loss or theft of any personal items left in any section of the rehabgym. A medication guide for lotronex must be given to the patient each time lotronex is dispensed as required by law. Only physicians who have enrolled in the prometheus prescribing program for. It is important that you follow all these instructions, exactly. 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. Contains confidential patient information lotronex alosetron. 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.
It is understood that any item may be placed in the hands of a person at. A patient followup survey program for lotronex alosetron. A patient is defined as those persons for whom the physician shall provide. Read and complete the patient physician agreement form provided by your doctor. Patient has any contraindications to the use of alosetron. Lotronex, the patient must read and sign the patient physician agreement see precautions. Before prescribing revlimid, your healthcare provider will explain the revlimid rems program to you and have you sign the patientphysician agreement form. Lotronex is a medicine only for some women with severe irritable bowel syndrome ibs whose main problem is diarrhea. 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.
Physicians should instruct patients to immediately report constipation or symptoms of ischemic colitis. The patient portal is designated to enhance patientphysician communications. Has the patient received and completed the lotronex medication guide. 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 medicine also has special laws that the doctor and patient must follow. Contains confidential patient information lotronex. By providing your email you are giving us permission to contact you in this way. If you see other doctors about your ibs or possible side effects from lotronexalosetron hydrochloride, tell the doctor who prescribed lotronexalosetron hydrochloride. Discontinue lotronex immediately if constipation occurs. I understand my signature indicates that i am in agreement with the previously outlined patient responsibilities. Recommended starting dosage was 1 mgday for 4 weeks. Answer all questions the patient may have about lotronex. Lotronex alosetron hydrochloride is a prescription medicine only for women with severe irritable bowel syndrome. 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.
Lotronex, alosetron dosing, indications, interactions. Management of irritable bowel syndrome american family. Sebela patient assistance program po box 219, gloucester, ma. Pharmacists were required to dispense a medication guide and were asked to check. Have both the patient and physician signed the patientphysician agreement. Lotronex may be dispensed only on presentation of a prescription for lotronex with a sticker for the prescribing program for lotronex attached. Patients should read the medication guide before starting alosetron and each time they re. This education sheet only discusses the most serious risk information of lotronex alosetron hydrochloride. You can tell if your ibs is severe if at least 1 of these is true. This form describes patient first s treatment and payment policies and covers such important topics as. Inability to comply with the patient physician agreement for lotronex. By providing your fax you are giving us permission to contact you in this way.
Lotronex, the patient must read and sign the patientphysician agreement see precautions. I understand that if i violate this agreement, i may be subject to termination of my primary physicianpatient relationship, as well as, physicians of. 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. Sebela patient assistance program po box 219, gloucester. I agree to adhere to the payment policy outlined by this office. Lotronexalosetron hydrochloride pharmacies are no longer required to only dispense lotronexalosetron hydrochloride for a paper prescription with an affixed prescribing program sticker. Understand that lotronex has serious risks for some people. Clinical efficacy of serotonin agonists and antagonists. We do not provide emergency services for users of our site.
Alosetron for irritable bowel syndrome pubmed central pmc. Your doctor will ask you to sign a patientphysician agreement after you have read the medication guide for the first time. 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. Before you begin taking revlimid, you must read and agree to all of the instructions in the revlimid rems program. Summary background alosetron was reintroduced for treatment of irritable bowel syndrome with a risk management programme in november 2002. Sign a patient physician agreement with your doctor. This education sheet only discusses the most serious risk information of lotronexalosetron hydrochloride. This list may help guide you and your doctor in selecting an appropriate medication for you. Also, be sure to get a medication guide from your pharmacist, and then read it carefully.