Prescribing INBRIJA

INBRIJA^®—the only inhaled levodopa for on-demand use in patients taking CD/LD.²¹
Here are 2 ways to prescribe INBRIJA*:

ePRESCRIBE
PATIENT
ENROLLMENT FORM

ePrescribe INBRIJA in 2 simple steps

Find and select Pacific LTC Pharmacy in your EMR by searching one of the options below:

Fax:
1-949-524-3566
(Recommended)
NCPDP: 5664417
NPI: 1871002485
Address:
361 Hospital Rd., Ste 425
Newport Beach, CA 92663

Include patient's current mobile phone number.^†

Chart notes and additional information

Fax chart notes or other information to 1-844-317-5359

Tell your patient to expect a text^‡ or phone call from an 844 area code within 1 to 2 hours of sending the eRx to complete enrollment and confirm next steps, including prescription fulfillment.

print instructions

Complete the Patient Enrollment Form

(Formerly known as Prescription Request Form)

FILL OUT FORM

Download and fill out a Patient Enrollment Form

FAX

Fax completed form to 1-949-264-1199

If you do not have access to a fax machine, call us at 1-833-INBRIJA (1-833-462-7452).

Patient Enrollment Form

*	Available at a variety of specialty pharmacies nationwide.
^†	You may receive a phone call from an INBRIJA patient support specialist if additional information is required to initiate prior authorization.
^‡	Standard text and data rates may apply.
	EMR, electronic medical record.