Health-care setting |
• Designate authorized representative |
• Health-care setting enrollment form |
Once with enrollment |
• Train staff |
|
|
• Establish processes and procedures |
|
|
• Obtain authorization to dispense each dose |
• REMS checklist |
Each dispense |
Providers |
• Review prescribing information |
• Knowledge assessment |
Once with enrollment |
• Review program overview and education |
• Prescriber enrollment form |
|
• Complete knowledge assessment |
• Patient enrollment form |
|
• Enroll as prescriber |
|
|
• Counsel on ocular toxicity and ophthalmic evaluations |
|
|
• Enroll patient |
|
|
• Consult eye care professional |
• Eye care professional consult request form |
Each treatment |
• Assess consult |
• Patient status form |
|
Patients |
• Receive counseling |
• Patient enrollment form |
Each treatment |
• Enroll |
|
|
• Attend ophthalmic exams |
|
Each treatment |