Fill out this form with the help of your doctor or nurse to enroll in the R-Pharm US Access and Support program. This program offers helpful access and support resources. It can help review what benefits are covered under your plan for R-Pharm US medicines. It can also assist with the cost of your medicine if you have no active insurance.
R-Pharm US Access and Support patient authorization form
Fill out this form to allow the R-Pharm US Access and Support program to provide you with services and assistance. This form should be used only if you filled out an R-Pharm US Access and Support enrollment form but did not sign it.
The information provided is intended for use by individuals involved with reimbursement support.
The accurate completion of reimbursement or coverage-related documentation is the responsibility of the healthcare provider and patient. R-Pharm US and its agents make no guarantee regarding reimbursement for any service or item.
IXEMPRA is a prescription medicine used to treat locally advanced or metastatic breast cancer when certain other medicines have not worked or no longer work. IXEMPRA can be used alone or with another cancer medicine called Xeloda® (capecitabine).
Important Safety Information about IXEMPRA
You should not have your injection of IXEMPRA if you:
Are allergic to medicines that contain Cremophor® EL (polyoxyethylated castor oil)
Have a low white blood cell count or a low platelet count
Before you receive treatment with IXEMPRA, tell your healthcare provider about all of your medical conditions, including any of the following:
Heart problems or a history of heart problems
An allergic reaction to IXEMPRA. (To lower the chance of an allergic reaction, you will receive other medicines about 1 hour before each dose of IXEMPRA)
Numbness, tingling, or burning in the hands or feet (neuropathy)
You should also tell your healthcare provider if you:
Are pregnant or plan to become pregnant. IXEMPRA may harm your unborn baby
Are breast-feeding. It is not known if IXEMPRA passes into breast milk
Take any medicines, including prescription and nonprescription medicines, vitamins, and herbal supplements, including St John’s wort. IXEMPRA and certain other medicines may affect each other and cause side effects
While you are on treatment with IXEMPRA, you should avoid:
Activities that may be dangerous, such as driving or operating machinery because IXEMPRA contains alcohol and may cause dizziness and drowsiness (feeling tired)
Drinking grapefruit juice. Grapefruit juice may cause you to have too much IXEMPRA in your blood, and this can lead to side effects
IXEMPRA may cause serious side effects. Tell your healthcare provider right away if you have any of the following while taking IXEMPRA:
Numbness, tingling, or burning in the hands or feet (neuropathy). When they do happen, these symptoms often appear early in treatment and may be new or get worse. Your dose of IXEMPRA may need to be decreased, stopped until your symptoms get better, or stopped totally
Low white blood cell count (neutropenia). White blood cells help protect the body from infections caused by bacteria. Symptoms of neutropenia include fever (temperature over 100.5 degrees), chills, cough, and burning or pain when you urinate. If you get a fever or an infection when your white blood cell count is very low, you can become seriously ill and die. You may need treatment in the hospital with antibiotic medicines
Allergic reactions. Signs of an allergic reaction include itching; hives; rash; flushed face; sudden swelling of the face, throat, or tongue; tightness in the chest; trouble breathing; feeling dizzy or faint; feeling your heart beating (palpitations). Allergic reactions are most likely to occur while IXEMPRA is being injected. Severe allergic reactions can occur with IXEMPRA and may cause death in rare cases
Heart Problems. Chest pain, difficulty breathing, palpitations, or unusual weight gain. These can be caused by decreased blood flow to the heart, problems with heart function, and abnormal heartbeat
The most common side effects of IXEMPRA, when used alone or with capecitabine, may include:
Loss of appetite
Problems with your toenails and fingernails
Decreased red blood cell count (anemia)
Joint and muscle pain
Decreased platelet count (thrombocytopenia)
Nausea, vomiting, diarrhea, constipation, and abdominal pain
Sores on the lip, in the mouth, and in the esophagus
Tender, red skin on the palms of the hands and the soles of the feet (hand-foot syndrome). It may look like a sunburn. The skin may also become dry and peel or may feel numb and tingly
If you have any questions about your health or your medicines, talk with your healthcare provider.
Click here to see the Full Prescribing Information, including boxed WARNING regarding liver disease.