Download Instructions: Have a question? Call 1-888-507-5206 (M

phone: 888.507.5206 fax: 855.626.3537 hours: 9a-6p est, M-F
Please See Abstral® Boxed Warning and Important Safety Information on Reverse Side
Instructions:
1.
2.
3.
Select Services to be performed below
Have Patient fill in Section 1 and sign authorization
Prescriber to fill in Section 2 and sign certification
4. Fax this form, prescription, and copy of patient prescription insurance card to:
FAX: 855.626.3537
5. PLEASE BE SURE FORM IS COMPLETELY FILLED OUT
Have a question? Call 1-888-507-5206 (M-F 9 am – 6 pm EST)
Selection of Services (to be completed by Prescriber and Patient)
Please choose services:
 Abstral® Benefit Investigation/ Reimbursement Support

Locate Pharmacy that stocks Abstral®
 Abstral® CoPay Support (PLEASE NOTE: CoPay Support is not available for prescriptions reimbursed under Medicaid, a Medicare drug benefit plan, or other federal or stateprograms, such as
medical assistance programs. If you participate in one of these programs, you may qualify for other Reimbursement Supportoptions.)
Section 1 (To be completed by Patient):
Patient Information:
Name:
Date of Birth:
First
Middle Initial
/
/
Address:
Home Phone: (
Gender:
SSN (Optional):
City:
)
Male Female
Last
Cell Phone: (
)
State:
Zip:
.
Patient E-mail Address:
Patient Preferred Pharmacy:
.
City, State
. Phone #: (_
)
_.
Insurance Information:
Insurance: (please check all that apply) Please provide copies of all insurance and prescription cards with this enrollment form
 Private Insurance/Commercial

Medicare 
Medicaid
Insurance Name:

VA or Military

Unknown
Phone:
Group #:

None
ID/Policy#:
RX Bin #:
.
Policy Holder Name & DOB:
.
Patient Authorization (Please read thoroughly and sign below):
By signing this Authorization, I authorize my health plan, physicians, and pharmacy providers to disclose my personal health information, including but not limited to, information relating to my medical condition,
treatment, care management and health insurance, as well as all information provided on this form and any prescription (“Protected Health Information”), to Aureus Health Services and its representatives, agents and
contractors for the following purposes: (1) to establish my eligibility for benefits; (2) to communicate with my healthcare providers and me about my medical care; (3) to facilitate the provision of products, supplies, or
services by a third party including, but not limited to pharmacies; (4) to register me in any applicable product registration program if required for my treatment; and (5) to contact me with educational or treatment support
materials and requests for participation in patient programs related to treatment. This consent shall be valid for 36 months from date of execution of this form, unless revoked by me in writing.
I understand that I may refuse to sign the Authorization. I also understand that my signing of this authorization is required for enrollment, or eligibility for benefits in this Program. I understand that based on type of
insurance I have I may not be eligible for some or all of the programs offered by Sentynl Patients Services. I understand that I am entitled to a copy of this Authorization. I understand that I may cancel this Authorization at
any time by mailing a letter requesting such cancellation to SENTYNL c/o Aureus Health Services 305 Merchant Lane Pittsburgh, PA 15205, but that this cancellation will not apply to any information already used or
disclosed through this Authorization.
I have read this authorization and agree to its terms:
.
Print Name of Patient or Personal Representative
.
Description of Personal Representative’s Authority
X
.
.
Signature of Patient or Personal Representative
Date
Section 2 (To be completed by Prescriber):
Prescriber Name:
State License#:
Prescriber NPI#:
Facility Name:
Phone: (
Facility Address:
City:
Primary Contact Name:
Phone: (
Primary Contact E-mail Address:
Title:
Prescriber Tax ID#:
)
Fax: (
)
State:
)
Fax: (
.
.
Zip:
.
)
.
.
Patient Medical Information:
ICD-10 Code:
Previous opioid, if any (optional):
.
Prescriber Certification (Please read thoroughly and sign below):
I certify to the following:
(1) To the best of my knowledge, the patient and prescriber information in this form is complete, and accurate. (2) I have the authority to disclose this patient’s information and have obtained, if required by HIPAA or other
applicable privacy laws or regulations, this patient’s authorization for the disclosure. (3) To the best of my knowledge, this patient satisfies the eligibility criteria and I will immediately notify the Program if I become aware
that this patient’s insurance or income status has changed. (4) I have read and agree to all of the Terms and Conditions of the Program. (5) To the best of my knowledge, participation in this Program is not inconsistent with
any contract or arrangement with any third-party payer to which this office/site will submit a bill or claim for reimbursement for a covered Sentynl Therapeutics, Inc. (Sentynl) product administered to the patient. (6) This
office/site will comply with applicable obligations, if any, to disclose participation in this Program to the applicable payers. (7) The bill or claim that this office/Site will submit to the insurer or patient for payment for a
covered Sentynl product will have a covered Sentynl product listed separately from any bill or claim for drug administration or any other items or services provided to the patient. (8) I will not submit an insurance claim or
other claim for payment to any third-party payer (private or government) for the amount of assistance that my patient received from the Program. (9) If this office/site receives payment directly from the Program for this
patient, the office/site will not accept payment from the patient for the amount received from the Program. I will ensure payment is made back to the patient if funds have already been received from the patient for their
share of the cost of a covered Sentynl product for any dates of service paid through the Program.
I understand that:
(1) Sentynl reserves the right to verify all information provided by prescribers, suspend participation where inadequate information is provided, and limit enrollment based on available resources. (2) Sentynl reserves the
right to modify or terminate this Program, or recall or discontinue medication, at any time without notice. (3) Sentynl is relying on the certifications in this form. (4) The Program reserves the right to not provide assistance
until an accurate and complete application with a signed certification is received, along with any other required documentation.
Please sign and date below and fax back to the Sentynl Patient Services at 855.626.3537. An original prescriber signature is required. Stamped signatures or signatures by persons other than the prescribing healthcare
official are not acceptable. We will be unable to process the patient’s request for assistance until we receive a complete application with your certification and patient’s signature. If you have any questions, please call the
Sentynl Patient Services at 888.507.5206.
Original Signature of Prescriber: X
Prescriber’s Name (Please Print):
Date:
Please See Abstral® Boxed Warning and Important Safety Information on Reverse Side
.
phone: 888.507.5206 fax: 855.626.3537 hours: 9a-6p est, M-F
Important Safety Information
ABSTRAL® (fentanyl) sublingual tablets CII
ABSTRAL® (AB-stral) sublingual tablets are used to manage breakthrough pain in adults with cancer (18 years of age and older) who are already routinely taking other
opioid pain medicines around-the-clock for cancer pain.
IMPORTANT:
Do not use ABSTRAL unless you are regularly using another opioid pain medicine around-the-clock for your cancer pain and your body is used
to these medicines (this means that you are opioid tolerant). Keep ABSTRAL in a safe place and away from children or anyone for whom it has
not be prescribed.
Get emergency medical help right away if:
 a child takes ABSTRAL. ABSTRAL can cause an overdose and death in any child who takes it.
 an adult who has not been prescribed ABSTRAL takes it
 an adult who is not already taking opioids around-the-clock, takes ABSTRAL
These are medical emergencies that can cause death. If possible, try to remove ABSTRAL from the mouth.
Read the Medication Guide that comes with ABSTRAL completely before you start taking ASBTRAL, and each time you get a new prescription. There may be new
information. The Medication Guide does not take the place of talking to your healthcare provider about your medical condition or your treatment. Be sure to share
this important information with members of your household and other caregivers.
Abstral can cause life-threatening breathing problems that can lead to death:
-don’t take ABSTRAL if you are not opioid tolerant, meaning you must be already taking another opioid (narcotic) around-the-clock for your cancer pain.
-if you stop taking your around-the-clock opioid pain medicine for your cancer, you must stop taking Abstral, as you may no longer be opioid tolerant.
-take ABSTRAL only as prescribed by your healthcare provider. You must not take more than 2 doses of ABSTRAL for each episode of breakthrough cancer pain.
-you must wait 2 hours before treating a new episode of breakthrough cancer pain with ABSTRAL.
-don’t switch from ABSTRAL to any other fentanyl containing product without talking with your healthcare provide, as it may result in fatal overdose.
-only use ABSTRAL for the purpose it was prescribed. Never give it to anyone else, even if they have the same symptoms. It may harm them or cause death.
ABSTRAL is a prescription narcotic medicine that contains fentanyl. It is intended to be used only to treat pain in cancer patients (18 years of age and older) who are
already routinely taking other opioid pain medicines around-the-clock for cancer pain. It should be prescribed only by healthcare professionals who are
knowledgeable of, and skilled in the use of, Schedule II opioids to treat cancer pain.
Don’t take ABSTRAL:
-if you are not opioid tolerant.
-if you are allergic to any of the ingredients in ABSTRAL
-for short-term pain that you would expect to go away in a few days, such as pain after surgery, headache, migraine, or dental pain.
ABSTRAL is only available through a program called the TIRF REMS Access program. To receive ABSTRAL, you must talk to your healthcare provider, understand the
benefits and risks of ABSTRAL, agree to all of the instructions, and sign the Patient-Prescriber Agreement form.
Before taking ABSTRAL tell your healthcare provider if you:
-have trouble breathing or have long problems such as asthma, wheezing, or shortness of breath,
-have or had a head injury, seizures, or brain problems,
-have a slow heart rate, low blood pressure, or other heart problems,
-have metal health problems, including major depression, schizophrenia, or hallucinations,
-have a past or present drinking or drug abuse problem, or a family history,
-are or plan to become pregnant or breastfeed, as ABSTRAL may cause serious harm to your unborn or nursing baby,
-are taking any prescription, non-prescription, vitamins, or herbal supplements before you begin to take ABSTRAL.
How to Take ABSTRAL
-Take ABSTRAL exactly as prescribed. Don’t take more or more often than prescribed.
-Place the tablet under your tongue and let it dissolve completely. Do not suck, chew or swallow the tablet.
-Take 1 dose for episode of breakthrough cancer pain. If not better within 30 minutes, take 1 more dose. You may not take more than 2 doses per episode
-Wait at least 2 hours after the last dose of the previous episode before treating a new episode of breakthrough cancer pain.
-It is important to continue to take your around-the-clock pain medication.
-Be very careful taking other medicines that may make you sleepy, such as anti-depressants, sleeping pills, antihistamines, or tranquilizers.
-Do not drink alcohol while taking ABSTRAL. Do not drive, operate heavy machinery, or do dangerous activities until you know how ABSTRAL affects you.
ABSTRAL can make you sleepy. Ask your healthcare provider when it is ok to do these activities.
Possible side effects of ABSTRAL are:
-Abstral can cause life-threatening breathing problems that can lead to death
-Decreased blood pressure, which can make you feel dizzy or lightheaded if you get up too fast from sitting or lying down.
-Potential for addiction, abuse, and physical dependence. Do not stop taking ABSTRAL or any opioid without talking to your healthcare provider.
-Most common side effects are nausea, sleepiness, and headache.
-Constipation is a very common side effect of pain medicines (opioids) including ABSTRAL, and unlikely to go away without treatment.
You or a family member should call your healthcare provider or get emergency medical help right away if you:
• have trouble breathing, as these can be life-threatening,
• have drowsiness with slowed breathing,
• have shallow breathing (little chest movement with breathing),
• feel faint, very dizzy, confused, or have other unusual symptoms.
These symptoms can be a sign that you have taken too much ABSTRAL or the dose is too high for you. These symptoms may lead to serious problems or death if not
treated right away. If you have any of these symptoms, do not take any more ABSTRAL until you have talked to your healthcare provider.
Abstral® is a federally controlled substance (CII) available by prescription only.
This information is not intended to replace discussions with your doctor.
For Full Prescribing Information visit: www.dailymed.nlm.nih.gov.
©2016 All Rights Reserved. Sentynl Therapeutics, Inc. PM-AB-2016002.00