Treatments & Provider Forms v2

**If referring office sending over someone with “WNL” lab values- documentation of explanation of why treatment is being ordered/recommended will be required.

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Nucala

Requirements:

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

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Nulojix

Requirements:

Negative TB results

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

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Ocrevus

Requirements:

Negative Hep B

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Baseline liver function tests (LFTs) (ALT, AST, bilirubin, alkaline phosphatase) within 6 months

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Ocrevus Zunovo

Requirements:

Negative Hep B

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Baseline liver function tests (LFTs) (ALT, AST, bilirubin, alkaline phosphatase) within 6 months

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Omvoh

Requirements:

Negative TB test

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

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Onpattro

Requirements:

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

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Orencia

Requirements:

Negative TB

Negative Hep B

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

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Pemgarda

Requirements:

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

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Phesgo

Requirements:

Documentation of which combined therapy patient is currently on

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

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Prolia & Biosimilars

Requirements:

Normal calcium within 6 months of referral

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

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Qutenza

Requirements:

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

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Reclast

Requirements:

Normal calcium within 6 months of referral

Serum creatinine within 6 months of referral

Calculated creatinine clearance MUST be greater than 30 mL/min using the Cockcroft-gault equation

Demographics

Labs & Tests Supporting Diagnoses and Labs & Tests Supporting Diagnoses

Start Referral

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Remicade & Biosimilars

Requirements:

Negative TB

Negative Hep B results

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

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Rituxan & Biosimilars

Requirements:

Negative Hep B

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

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Rystiggo

Requirements:

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

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Sandostatin LAR Depot

Requirements:

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

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Saphnelo

Requirements:

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

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Simponi Aria

Requirements:

Negative TB

Negative Hep B

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

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Skyrizi

Requirements:

Negative TB Screening

Demographics

Labs & Test Supporting Diagnoses

Office / Progress Notes

Start Referral

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Soliris

Requirements:

Documentation of meningitis vaccine (at least 2 weeks before 1st infusion)

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

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Solu-Medrol

Requirements:

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

Download Form

Spevigo

Requirements:

Negative TB

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

Download Form

Stelara & Biosimilars

Requirements:

Negative TB

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

Download Form

Tepezza

Requirements:

Thyroid panel within 6 months of referral prior to initiation of therapy

Hearing test completed prior to treatment

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

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Tezspire

Requirements:

Start Referral

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Tremfya

Requirements:

Negative TB test

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

Download Form

Tyruko

Requirements:

Negative Hep B

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

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Tysabri

Requirements:

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

TOUCH portal enrollment

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Ultomiris

Requirements:

Proof of meningococcal vaccination at least 2 weeks prior to start of treatment

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

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Uplizna

Requirements:

Negative Hep B

Negative TB

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

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Venofer

Requirements:

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Complete blood count (CBC) and iron studies, such as ferritin or iron level, indicating iron deficiency or anemia within six months of starting therapy.

If sending over someone with “WNL” lab values- documentation of explanation of why treatment is being ordered/recommended will be required.

Start Referral

Download Form

Vitamin B 12 Injection

Requirements:

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

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Vyepti

Requirements:

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

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Vyvgart

Requirements:

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

Download Form

Vyvgart Hytrulo

Requirements:

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

Download Form

Xgeva

Requirements:

Normal calcium within 6 months of referral

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

Download Form

Xolair

Requirements:

Demographics

Labs & Tests Supporting Diagnoses

Office/Progress Notes

Start Referral

Download Form

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We Accept All Major Plans & Cash Options

We work with all our medication providers to ensure that our patients receive every opportunity to reduce their costs

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We Accept All Major Plans & Cash Options

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