Download the form, complete it with your patient, including HCP and patient signatures, and submit by fax or email. Bookmark this page for next time!
Complete the form and send to your patient via email to sign electronically via DocuSign®.
Patient Enrollment Form ChecklistImportant checklist detailing steps to enroll, educate, and connect TEPEZZA patients with PALs for successful treatment.
TEPEZZA At Your Practice A guide to clinical, access, and reimbursement considerations for TEPEZZA.
Site of Care (SOC) Guide Helpful information to consider when selecting a site of care for your patient’s infusion of TEPEZZA.
Care Team Notification A customizable letter used to notify co-managers and coordinate patient monitoring when TEPEZZA is initiated.
Home Infusion FAQsAnswers to common questions about home infusion for TEPEZZA.
Home Infusion Brochure Considerations for choosing home infusion for TEPEZZA.
Clinical Documentation Guide A guide to documenting TED symptomatology with a focus on capturing key clinical criteria, such as Clinical Activity Score (CAS).
Clinical Documentation Tearpad A form that outlines the CAS that is used to evaluate the inflammatory signs and symptoms of TED.
Letter of Medical Necessity Template A customizable template for a letter of medical necessity to support PA for TEPEZZA.
Payor Appeal Letter Template A customizable appeals template for patient cases that were denied PA.
Acquisition Overview A guide to TEPEZZA specialty distributors, specialty pharmacies, and ordering.
Product Fact Sheet Product information, including NDC, packaging, storage, handling, and authorized distributor list.
Billing and Coding Guide A guide to billing procedures, necessary codes, and reimbursement with J-code.
Coding at a Glance A guide to necessary codes for billing and reimbursement with J-code.
Infusion Checklist A step-by-step checklist for the infusion process.
Infusion Manual A detailed guide to preparing, administering, and infusing TEPEZZA.
Infusion Administration Video Key steps required for reconstitution, dilution, and administration of TEPEZZA.
Getting Started on TEPEZZA Patient Brochure A brochure to guide your patients through the initial steps of getting started on TEPEZZA.
Getting Started on TEPEZZA Video A video to help your patients understand how to get started on TEPEZZA.
TEPEZZA PSK Insurance Approval GuideA brochure to guide your patients through insurance coverage and approval of TEPEZZA.
TEPEZZA Pre-Infusion Reminder List A list that helps your patients prepare for TEPEZZA infusions.
TEPEZZA Post-Infusion Reminder List A list that helps your patients stay on track after each TEPEZZA infusion.
For additional resources for your practice, please visit Amgen By Your Side.
For additional resources for your patients, please visit TEPEZZA patient website.
Infusion Reactions: TEPEZZA may cause infusion reactions. Infusion reactions have been reported in approximately 4% of patients treated with TEPEZZA. Reported infusion reactions have usually been mild or moderate in severity. Signs and symptoms may include transient increases in blood pressure, feeling hot, tachycardia, dyspnea, headache, and muscular pain. Infusion reactions may occur during an infusion or within 1.5 hours after an infusion. In patients who experience an infusion reaction, consideration should be given to premedicating with an antihistamine, antipyretic, or corticosteroid and/or administering all subsequent infusions at a slower infusion rate.
Preexisting Inflammatory Bowel Disease: TEPEZZA may cause an exacerbation of preexisting inflammatory bowel disease (IBD). Monitor patients with IBD for flare of disease. If IBD exacerbation is suspected, consider discontinuation of TEPEZZA.
Hyperglycemia: Increased blood glucose or hyperglycemia may occur in patients treated with TEPEZZA. In clinical trials, 10% of patients (two-thirds of whom had preexisting diabetes or impaired glucose tolerance) experienced hyperglycemia. Hyperglycemic events should be controlled with medications for glycemic control, if necessary. Assess patients for elevated blood glucose and symptoms of hyperglycemia prior to infusion and continue to monitor while on treatment with TEPEZZA. Ensure patients with hyperglycemia or preexisting diabetes are under appropriate glycemic control before and while receiving TEPEZZA.
Hearing Impairment Including Hearing Loss: TEPEZZA may cause severe hearing impairment including hearing loss, which in some cases may be permanent. Assess patients’ hearing before, during, and after treatment with TEPEZZA and consider the benefit-risk of treatment with patients.
The most common adverse reactions (incidence ≥5% and greater than placebo) are muscle spasm, nausea, alopecia, diarrhea, fatigue, hyperglycemia, hearing impairment, dysgeusia, headache, dry skin, weight decreased, nail disorders, and menstrual disorders.
TEPEZZA is indicated for the treatment of Thyroid Eye Disease regardless of Thyroid Eye Disease activity or duration.
Please see Full Prescribing Information for more information.
WARNINGS AND PRECAUTIONS Infusion Reactions: TEPEZZA may cause infusion reactions. Infusion reactions have been reported in approximately 4% of patients treated with TEPEZZA. Reported infusion reactions have usually been mild or moderate in severity. Signs and symptoms may include transient increases in blood pressure, feeling hot, tachycardia, dyspnea, headache, and muscular pain. Infusion reactions
