Download all fields are required. complete and fax this form to

P AT I E N T R E F E R R A L F O R M
ALL FIELDS ARE REQUIRED. COMPLETE AND FAX THIS FORM TO (855) 998-6951. FOR ASSISTANCE OR ADDITIONAL INFORMATION, CALL (855) 239-9869
Patient Information
1. PATIENT INFORMATION
2. INSURANCE INFORMATION
Name _______________________________ DOB _ _ / _ _ / _ _ _ _ Gender ______
Address ______________________________ City _________________________
State ___________ Zip code _______________ E-mail _____________________
Home phone ________________________ Cell phone _______________________
o Patient does not have insurance
o Insurance information provided below
o Copy of both sides of the patient’s insurance card attached
Primary insurance ____________________
Insurance phone ______________
Policy ID # ________________________ Group # _________________________
Policy holder name _________________ Relationship to patient _______________
Work phone _________________________ Best time to contact ______________
Pharmacy plan _______________ Preferred specialty pharmacy _______________
Patient representative _____________________ Phone ______________________
Policy ID # _______________ Group # ______ RX BIN # ______ RX PCN # ______
Med Profile
3. MEDICAL PROFILE ( INFORMATION NEEDED FOR PRIOR AUTHORIZATION SUPPORT )
Drug allergies______________________________________________________
Other concurrent medications ___________________________________________
Previously tried and failed therapies______________________________________
Culture results _____________________________________________________
Medication needed by date _ _ / _ _ / _ _ _ _
Height/weight _____________________________________________________
Expected date of discharge _ _ / _ _ / _ _ _ _
Prescription
4. PRESCRIPTION INFORMATION
o ZYVOX 600 mg tablets
o ZYVOX 600 mg oral suspension
Quantity _______
Take twice per day (every 12 hours)
For NY Prescribers, please provide prescription on NY state prescription form.
Case Mgr/Prescriber
5. PATIENT CASE MANAGER CONTACT INFORMATION
ZYVOXassist will utilize the preferred communication method below for outreach
regarding patient access to oral ZYVOX® (linezolid).
Contact name ______________________________________________________
Preferred communication method (please check AT LEAST one method)
o Phone _______________________________________________
o Fax _________________________________________________
o Pager _______________________________________________
o E-mail address _________________________________________
7. PRESCRIBER SIGNATURE [
Signature
Quantity _______
Take twice per day (every 12 hours)
6. PRESCRIBER INFORMATION
Prescriber name _____________________________ Specialty ________________
Hospital name _____________________________________________________
Collaborating physician _______________________________________________
Address __________________________________________________________
City ___________________________ State ________ Zip code _____________
State license # ________________________ NPI # ________________________
This form cannot be processed without physician’s signature below.
CHECK TO REQUEST BENEFITS INVESTIGATION ONLY. IF CHECKED, PLEASE SIGN BELOW AND LEAVE RX INFORMATION BLANK]
By signing this form, I certify that therapy with oral ZYVOX is medically necessary for this patient. I will be supervising the patient’s treatment accordingly and I have
reviewed the current oral ZYVOX prescribing information. I have received the necessary authorization to release medical and/or other patient information relating to oral
ZYVOX therapy to Pfizer and its affiliates, service providers, and agents to use and disclose my patient’s health information as necessary to participate in the ZYVOXassist
program, to verify the accuracy of any information provided, to provide reimbursement services, to forward the prescription below to a pharmacy for fulfillment, and (as
applicable) to assess my patient’s eligibility for patient assistance.
DOCTOR/PRESCRIBER SIGNATURE—DISPENSE AS WRITTEN DATE
Please see Important Safety Information and indications on reverse side.
P AT I E N T R E F E R R A L F O R M
IMPORTANT SAFETY INFORMATION
ZYVOX® (linezolid) use is contraindicated in patients with known hypersensitivity to ZYVOX or any of
the other product components.
ZYVOX should not be used in patients taking any medicinal product which inhibits monoamine
oxidases A or B (e.g. phenelzine, isocarboxazid) or within 2 weeks of taking any such product.
Myelosuppression (including anemia, leukopenia, pancytopenia, and thrombocytopenia) has been
reported in patients receiving ZYVOX. In cases where the outcome is known, when ZYVOX was
discontinued, the affected hematologic parameters have risen toward pretreatment levels. Complete
blood counts should be monitored weekly in patients who receive ZYVOX, particularly in those who
receive ZYVOX for longer than two weeks, those with pre-existing myelosuppression, those receiving
concomitant drugs that produce bone marrow suppression, or those with a chronic infection who have
received previous or concomitant antibiotic therapy. Discontinuation of therapy with ZYVOX should be
considered in patients who develop or have worsening myelosuppression.
Peripheral and optic neuropathy have been reported primarily in patients treated with ZYVOX for
longer than the maximum recommended duration of 28 days. If patients experience symptoms of
visual impairment, prompt ophthalmic evaluation is recommended. If peripheral or optic neuropathy
occurs, the continued use of ZYVOX in these patients should be weighed against potential risks.
Spontaneous reports of serotonin syndrome including fatal cases have been reported with the
co-administration of ZYVOX and serotonergic agents. Unless patients are carefully observed for
signs and/or symptoms of serotonin syndrome or neuroleptic malignant syndrome-like (NMS-like)
reactions, ZYVOX should not be administered to patients with carcinoid syndrome and/or patients
taking any of the following medications: serotonin reuptake inhibitors, tricyclic antidepressants,
serotonin 5-HT1 receptor agonists (triptans), meperidine, bupropion, or buspirone.
In some cases, a patient already receiving a serotonergic antidepressant or buspirone may require
urgent treatment with ZYVOX. If alternatives to ZYVOX are not available and the potential benefits of
ZYVOX outweigh the risks of serotonin syndrome or NMS-like reactions, the serotonergic antidepressant
should be stopped promptly and ZYVOX administered. The patient should be monitored for two weeks
(five weeks if fluoxetine was taken) or until 24 hours after the last dose of ZYVOX, whichever comes
first. The patient should also be monitored for discontinuation symptoms of the antidepressant.
A mortality imbalance was seen in an investigational study in ZYVOX-treated patients with
catheter-related bloodstream infections. ZYVOX is not approved and should not be used for the
treatment of patients with catheter-related bloodstream infections or catheter-site infections.
ZYVOX has no clinical activity against Gram-negative pathogens and is not indicated for the
treatment of Gram-negative infections. It is critical that specific Gram-negative therapy be
initiated immediately if a concomitant Gram-negative pathogen is documented or suspected.
Clostridium difficile associated diarrhea has been reported with use of nearly all antibacterial
agents, including ZYVOX, and may range in severity from mild diarrhea to fatal colitis.
Unless patients are monitored for potential increases in blood pressure, ZYVOX should not be
administered to patients with uncontrolled hypertension, pheochromocytoma, thyrotoxicosis and/or
patients taking any of the following: directly and indirectly acting sympathomimetic, vasopressive,
and dopaminergic agents.
Lactic acidosis has been reported with the use of ZYVOX. Patients receiving ZYVOX who develop
recurrent nausea, vomiting, unexplained acidosis, or a low bicarbonate level should receive immediate
medical evaluation.
Convulsions have been reported in patients treated with ZYVOX. In some of these cases, a history of
seizures or risk factors for seizures was reported.
Postmarketing cases of symptomatic hypoglycemia have been reported in patients with diabetes
mellitus receiving insulin or oral hypoglycemic agents when treated with ZYVOX, a reversible, nonselective MAO inhibitor. While a causal relationship between ZYVOX and hypoglycemia has not been
established, diabetic patients should be cautioned of potential hypoglycemic reactions when treated
with ZYVOX. If hypoglycemia occurs, a decrease in the dose of insulin or oral hypoglycemic agent, or
discontinuation of oral hypoglycemic agent, insulin, or ZYVOX may be required.
Prescribing ZYVOX in the absence of a proven or strongly suspected bacterial infection or a
prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the
development of drug-resistant bacteria.
The most commonly reported adverse events (>5%) in adults across phase 3 clinical trials were
diarrhea, nausea, and headache.
ZYVOX INDICATIONS
ZYVOX formulations are indicated in the treatment of the following infections caused by susceptible
strains of the designated microorganisms. ZYVOX is not indicated for the treatment of Gram-negative
infections. It is critical that specific Gram-negative therapy be initiated immediately if a concomitant
Gram-negative pathogen is documented or suspected.
Uncomplicated skin and skin structure infections caused by Staphylococcus aureus (methicillinsusceptible only) or Streptococcus pyogenes.
Nosocomial pneumonia caused by Staphylococcus aureus (methicillin-susceptible and -resistant
strains) or Streptococcus pneumoniae.
To reduce the development of drug-resistant bacteria and maintain the effectiveness of ZYVOX
and other antibacterial drugs, ZYVOX should be used only to treat or prevent infections that are
proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility
information are available, they should be considered in selecting or modifying antibacterial therapy.
In the absence of such data, local epidemiology and susceptibility patterns may contribute to the
empiric selection of therapy.
Complicated skin and skin structure infections, including diabetic foot infections, without concomitant
osteomyelitis, caused by Staphylococcus aureus (methicillin-susceptible and -resistant strains),
Streptococcus pyogenes, or Streptococcus agalactiae. ZYVOX has not been studied in the treatment of
decubitus ulcers.
Community-acquired pneumonia caused by Streptococcus pneumoniae, including cases with
concurrent bacteremia, or Staphylococcus aureus (methicillin-susceptible strains only).
Vancomycin-resistant Enterococcus faecium infections, including cases with concurrent bacteremia.
Pfizer’s service provider performing ZYVOXassist support services provides patient insurance
benefits verification as a service under contract for Pfizer Inc. ZYVOXassist support services
assist health care professionals in the determination of whether treatment could be covered by
the applicable third-party payer based on coverage guidelines provided by the payer, and
patient information provided by the health care provider under appropriate authorization
following the provider’s exclusive determination of medical necessity.
Many factors affect third-party reimbursement. Pfizer Inc and Pfizer’s service provider
performing the ZYVOXassist support services make no representation or guarantee that
insurance reimbursement or any other payment will be available. This service is for
informational purposes only. While Pfizer’s service provider performing ZYVOXassist support
ZVU623303-01 © 2014 Pfizer Inc. services tries to provide correct information, it and Pfizer Inc make no representations or
warranties, expressed or implied, as to the accuracy of the information. The support services
administrator, Pfizer Inc, or its employees or agents shall in no event be liable for any damages
resulting from or relating to the services. Responsibility for the use of this service is agreed
upon and accepted by all providers and other users of this information.
Pfizer Inc does not guarantee, and assumes no responsibility for the quality, scope, or
availability of the ZYVOXassist support services including but not limited to reimbursement
support services, patient education, and other support services. ZYVOXassist support services
are included within the cost of the product, and have no independent value to providers apart
from the product.
All rights reserved. Printed in USA/March 2014