A simple patient referral process.

Click the therapy below, and follow the three steps.

IVX Health primarily administers specialty biologic infusions and injections for those with complex chronic conditions. IVX Health updates its formulary on a consistent basis. To inquire about a specific therapy not listed below, please contact us.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Important Announcement

Payors and health plans often require patients to use a specified infliximab product, including Remicade, Unbranded Infliximab, Avsola, Inflectra, and/or Renflexis. All infliximab patient referrals are subject to review by IVX Health.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Important Exclusions for Iron Referrals

Due to increasing challenges with procurement of administration of iron products, IVX Health is currently only accepting limited iron referrals. Please contact your local IVX Health with additional questions.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Important Announcement

Payors and health plans often require patients to use a specified infliximab product, including Remicade, Unbranded Infliximab, Avsola, Inflectra, and/or Renflexis. All infliximab patient referrals are subject to review by IVX Health.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Important Announcement

Payors and health plans often require patients to use a specified infliximab product, including Remicade, Unbranded Infliximab, Avsola, Inflectra, and/or Renflexis. All infliximab patient referrals are subject to review by IVX Health.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Important Exclusions for Iron Referrals

Due to increasing challenges with procurement of administration of iron products, IVX Health is currently only accepting limited iron referrals. Please contact your local IVX Health with additional questions.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

All Leqvio orders require BOTH a primary and secondary ICD-10 code.

A Leqvio prescribing guide, including relevant ICD-10 codes, can be found here.
IVX cannot schedule a patient without this information, as all health plans require two diagnosis codes for prior authorization.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Important Announcement

Payors and health plans often require patients to use a specified infliximab product, including Remicade, Unbranded Infliximab, Avsola, Inflectra, and/or Renflexis. All infliximab patient referrals are subject to review by IVX Health.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Important Announcement

Payors and health plans often require patients to use a specified infliximab product, including Remicade, Unbranded Infliximab, Avsola, Inflectra, and/or Renflexis. All infliximab patient referrals are subject to review by IVX Health.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Important Announcement

IVX Health was recently notified by the pharmaceutical manufacturer Janssen that six Medicare Administrative Contractors (MACs) – Palmetto, Noridian, NGS, WPS, Novitas, and First Coast Service Options - are adding the subcutaneous (injectable) formulation of its biologic therapy STELARA to their Self-Administered Drug (SAD) Exclusion List. Effective dates for the policy changes are as follows:

  • October 15, 2021: Palmetto, Noridian, and NGS
  • November 15, 2021: WPS
  • June 6, 2022: Novitas and First Coast Service Options

Medicare will no longer cover STELARA SQ injections under the medical benefit (Part B) and instead will cover STELARA SQ under the prescription benefit (Part D). This change limits the ability of providers, including IVX, to administer STELARA for Medicare patients and generally requires patients remaining on STELARA SQ to self-administer the injection at home.

Due to this classification change, IVX Health is no longer accepting new STELARA SQ patients with Medicare in the following states:

  • Arkansas
  • California
  • Florida
  • Illinois
  • Indiana
  • Kansas / Missouri
  • Pennsylvania
  • Tennessee
  • Railroad Medicare patients in all states

NOTE: IVX Health will continue to accept STELARA IV patients with Medicare.

This change has immediate ramifications to patient care at IVX Health. IVX Health is proactively notifying referring providers about the classification change and the appropriate next steps for their patients. If you are an existing STELARA SQ patient at IVX Health and live in one of the aforementioned states, please contact your local IVX Health center immediately to discuss next steps.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Important Announcement

Payors and health plans often require patients to use a specified infliximab product, including Remicade, Unbranded Infliximab, Avsola, Inflectra, and/or Renflexis. All infliximab patient referrals are subject to review by IVX Health.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Important Exclusions for Iron Referrals

Due to increasing challenges with procurement of administration of iron products, IVX Health is currently only accepting limited iron referrals. Please contact your local IVX Health with additional questions.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Step 1

Review our Referral Checklist.

Step 2

Complete the therapy-specific Order Form.

Step 3

Gather the supporting clinicals.

That's it! You may fax or upload the information to us, and we take care of the rest.

Need help? Call us anytime at (800) 746-8147.

Please include the following information when submitting a referral for Actemra:
  • Results of a recent tuberculosis (TB) skin/lab testing
  • Clinicals to support one or more of the following:
    • Patient has moderately to severely active rheumatoid arthritis (RA) who has had an inadequate response to one or more disease modifying anti-rheumatic drugs (DMARDs)
    • Patient has giant cell arteritis (GCA)
    • Patient has active polyarticular juvenile idiopathic arthritis
    • Patient has active systemic juvenile idiopathic arthritis

Important Announcement

On June 17, 2022, the pharmaceutical manufacturer AbbVie announced that its product Skyrizi® received FDA approval for the treatment of moderately to severely active Crohn’s disease in adults.

The prescribing information for Skyrizi for the treatment of Crohn’s disease includes the administration of three intravenous infusion treatments over an 8-week period, followed by the ongoing self-administration of a subcutaneous injection. The three initial infusions must be administered by a healthcare professional, and IVX Health is now accepting Skyrizi IV referrals.

NOTE: Both the IV infusion formulation and indication for Crohn’s disease were recently approved by the FDA, and many healthcare payors have yet to officially recognize the new formulation and indication in their health insurance plans. IVX’s ability to receive a prior authorization for treatment may be temporarily delayed.

IVX Health is actively communicating with each of the healthcare payors and will proactively update both patients and referring providers as the issue is resolved.

At IVX, patients are our number one priority. If you have any additional questions, please contact your local IVX Health center immediately to discuss next steps.

Please include the following information when submitting a referral for Aduhelm:
  • Brain MRI within one year before starting treatment
    The patient will be required to complete three MRIs at different stages of the ADUHELM therapy regimen. The first must be completed before therapy starts, and the next MRIs must be completed after the sixth and eleventh infusion. IVX Health does not order or administer these MRIs. Patients must work with their referring physician to complete these diagnostic tests.
  • Cognitive test showing patient has reached the clinical stages for Alzheimer’s disease defined as mild cognitive impairment or mild dementia
    Patients must receive a cognitive test showing mild cognitive impairment or mild dementia prior to receiving ADUHELM at IVX Health Patients should work with their referring physician to complete this diagnostic test.
  • Confirmation of Amyloid Beta Pathology – either in the form of an Amyloid Beta Pet Scan or through Cerebral Spinal Fluid (CSF) biomarker testing
    Biogen is providing CSF biomarker test at no charge to patients through LabCorp and Mayo Clinic. The Amyloid βeta Confirmed™ program is being offered to help improve patient access to CSF biomarker testing to help support timely and accurate diagnosis of AD.
Please include the following information when submitting a referral for Amvuttra:
  • Supporting documentation of the diagnosis of hereditary transthyretin-mediated (hATTR) amyloidosis.
Please include the following information when submitting a referral for Aralast NP:
  • Clinical information that supports the diagnosis of adults with clinically evident emphysema due to severe hereditary deficiency of Alpha1-PI (alpha1-antitrypsin deficiency)
Please include the following information when submitting a referral for Benlysta:
  • Clinicals to support that the patient has active, autoantibody-positive, systemic lupus erythematosus (SLE) and is receiving standard therapy
Please include the following information when submitting a referral for Briumvi:
  • Hepatitis B virus screening and quantitative serum immunoglobulin screening are required before first dose (2.1)
Please include the following information when submitting a referral for Cerezyme:
  • Clinicals to support one or more of the following:
    • Type 1 Gaucher disease that results in one or more of the following conditions; anemia, throbocytopenia, bone disease, hepatomegaly or splenomegaly.
Please include the following information when submitting a referral for Cimzia:
  • Results of a recent tuberculosis (TB) skin/lab testing
  • Patient's current weight and height
  • Clinicals to support one or more of the following:
    • Patient has moderately to severely active rheumatoid arthritis (RA)
    • Patient has active psoriatic arthritis
    • Patient has active ankylosing spondylitis
    • Patient has active moderately to severely Crohn's disease who has had an inadequate response to conventional therapy
    • Patient has moderate to severe plaque psoriasis (PSO) who is a candidate for systemic therapy or phototherapy
Please include the following information when submitting a referral for Cinqair:
  • Lab results showing elevated eosinophil levels
  • List of current medications treating severe asthma
  • Patient has severe asthma with an eosinophilic phenotype and is 18 years of age or older
  • FEV1 test results
Please include the following information when submitting a referral for Cosentyx IV:
  • Result of Tuberculosis (TB) skin/ lab testing
  • Clinicals to support one or more of the following:
    • Patient has active psoriatic arthritis (PsA)
    • Patient has active ankylosing spondylitis (AS)
    • Patient has active non-radiographic axial spondyloarthritis (nr-axSpA)
Please include the following information when submitting a referral for Crysvita:
  • Clinicals to support one or more of the following:
    • Patient has X-linked hypophosphatemia (XLH)
    • Patient is 6 months of age or older
Please include the following information when submitting a referral for Elaprase:
  • Office notes with presence of clinical signs and symptoms of the disease and Molecular genetic testing for deletion or mutations in the iduronate 2-sulfatase gene
Please include the following information when submitting a referral for Elfabrio:
  • Patient has Fabry disease
Please include the following information when submitting a referral for Entyvio:
  • Results of a recent tuberculosis (TB) skin/lab testing
  • Patient's current weight and height
  • Clinicals to support one or more of the following:
    • Patient has moderately to severely active Crohn’s disease (CD)
    • Patient has moderately to severely active ulcerative colitis (UC)
Please include the following information when submitting a referral for Fabrazyme:
  • Clinicals to support that the patient has Fabry disease
Please include the following information when submitting a referral for Fasenra:
  • List of current medications treating disease
  • Lab results showing eosinophil count
  • Clinicals showing number of asthma exacerbations in the last 12 months
  • Clinicals showing that the patient has severe asthma and has an eosinophilic phenotype
  • FEV1 test results
Please include the following information when submitting a referral for Feraheme:
  • Most recent labs results
  • Patient has iron deficiency anemia
Please include the following information when submitting a referral for Givlaari:
  • Current height and weight
Please include the following information when submitting a referral for Glassia:
  • Clinical information that supports the diagnosis of adults with clinically evident emphysema due to severe hereditary deficiency of Alpha1-PI (alpha1-antitrypsin deficiency)
Please include the following information when submitting a referral for HyQvia:
  • Clinicals to support one or more of the following:
    • Primary immunodeficiency (PI) in people 2 years and older
    • Chronic inflammatory demyelinating polyneuropathy (CIPD) in adults
Please include the following information when submitting a referral for Ilaris:
  • Office notes with presence of clinical signs and symptoms of the disease
  • Result of Tuberculosis (TB) skin/ lab testing
Please include the following information when submitting a referral for Ilumya:
  • Clinicals to support one or more of the following:
    • Moderate-to-severe plaque psoriasis
When submitting a referral for IVIG, please include clinical documentation to support a diagnosis for the following indications:
Gamunex-C
Indications:
  • Primary humoral immunodeficiency (PI) in patients 2 years of age and older.
  • Idiopathic Thrombocytopenic Purpura (ITP) to raise platelet counts to prevent bleeding or to allow a patient with ITP to undergo surgery.
  • Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) to improve neuromuscular disability and impairment and for maintenance therapy to prevent relapse.

Gammagard Liquid
Indications:
  • Replacement therapy for primary humoral immunodeficiency (PI) in adult and pediatric patients two years of age or older.
  • Maintenance therapy to improve muscle strength and disability in adult patients with Multifocal Motor Neuropathy.

Gammagard S-D 5%
Indications:
  • Treatment of Primary Immunodeficiency (PI) in adults and pediatric patients two years of age or older
  • Prevention and/or control of bleeding in adult Chronic Idiopathic Thrombocytopenic Purpura (ITP) patients

Octagam
Indications:
  • Octagam is an immune globulin intravenous (human), 5% liquid, indicated for treatment of primary humoral immunodeficiency (PI)
  • Chronic immune thrombocytopenic purpura (ITP) in adults.
  • Dermatomyositis (DM) in adults.

Privigen
Indications:
  • Primary humoral immunodeficiency (PI)
  • Chronic immune thrombocytopenic purpura (ITP) in patients age 15 years and older
  • Chronic inflammatory demyelinating polyneuropathy (CIDP) in adults

NOTE: For almost all of the IVIG therapies, it is recommended to monitor renal function in patents at risk of acute renal failure.

Please include the following information when submitting a referral for Krystexxa:
  • Perform serum uric acid (sUA) test prior to each infusion
  • Screen patients at risk for G6PD deficiency prior to starting therapy
  • Patient had chronic gout and is an adult patient who have failed to normalize serum or has shown an inadequate response to conventional therapy
Please include the following information when submitting a referral for Lemtrada:
  • Most recent lab results
  • Results of a recent tuberculosis (TB) skin/lab testing
  • Results of HIV testing
  • Patient has relapsing-remitting multiple sclerosis (RRMS) who has had an inadequate response to two or more drugs indicated for the treatment of MS
  • Baseline labs as required by REMS program
  • Results of Hep C testing
Please include the following information when submitting a referral for Leqvio:
  • Patient must be on and continue to be on statin therapy or patient must have an intolerance to statin
  • All Leqvio orders require BOTH a primary and secondary ICD-10 code.
A Leqvio prescribing guide, including relevant ICD-10 codes, can be found here.
Please include the following information when submitting a referral for Lumizyme:
  • Patient is 8 years and older with late (non-infantile) onset Pompe disease (GAA deficiency) who has no evidence of cardiac hypertrophy
Please include the following information when submitting a referral for Nexviazyme:
  • Patient is 8 years and older with late (non-infantile) onset Pompe disease (GAA deficiency) who has no evidence of cardiac hypertrophy
Please include the following information when submitting a referral for Injectafer:
  • Most recent lab results
  • Patient has iron deficiency anemia
Please include the following information when submitting a referral for Nucala:
  • List of current medications treating disease
  • Labs showing elevated eosinophil count of 150 cells/uL or higher
  • Clinicals showing number of asthma exacerbations in the last 12 months
  • FEV1 test results
  • Clinicals to support one or more of the following:
    • Add-on maintenance treatment of adult and pediatric patients aged 6 years and older with severe asthma and with an eosinophilic phenotype
    • Add-on maintenance treatment of adult patients 18 years and older withchronic rhinosinusitis with nasal polyps (CRSwNP)
    • The treatment of adult patients with eosinophilic granulomatosis with polyangiitis (EGPA)
    • The treatment of adult and pediatric patients aged 12 years and older with hypereosinophilic syndrome (HES) for ≥6 months without an identifiable non-hematologic secondary cause
Please include the following information when submitting a referral for Nulojix:
  • List of current medications treating disease
  • Patient has history of prophylaxis of organ rejection and is receiving a kidney transplant
Please include the following information when submitting a referral for Ocrevus:
  • Results of a Hepatitis B virus lab
  • Quantitative serum immunoglobulin results
  • Clinicals to support one or more of the following:
    • Patient has relapsing multiple sclerosis (RMS)
    • Patient has primary progressive multiple sclerosis (PPMS)
    • Patient has secondary progressive multiple sclerosis (SPMS)
Please include the following information when submitting a referral for Omvoh:
  • Result of Tuberculosis (TB) skin/ lab testing
  • Baseline Liver Enzymes and Bilirubin
Please include the following information when submitting a referral for Onpattro:
  • Supporting documentation of the diagnosis - Hereditary transthyretin-mediated (hATTR) amyloidosis.
Please include the following information when submitting a referral for Orencia:
  • Patient's current weight and height
  • Clinicals to support one or more of the following:
    • Patient has rheumatoid arthritis (RA)
    • Patient has juvenile idiopathic arthritis (JIA)
    • Patient has psoriatic arthritis
Please include the following information when submitting a referral for Oxlumo:
  • current height and weight
Please include the following information when submitting a referral for Prolastin-C:
  • Patient has shown clinical evidence of emphysema due to severe hereditary deficiency of Alpha-1 antitrypsin deficiency
Please include the following information when submitting a referral for Infliximab (Remicade, Inflectra, Renflexis, Avsola):
  • Result of Tuberculosis (TB) skin/ lab testing
  • Hepatitis B status & date
  • Patients current weight and height
  • Clinicals to support one or more of the following:
    • Patient has active moderate to severe Crohn’s disease (CD)
    • Patient has active moderately to severely active Ulcerative Colitis (UC)
    • Patient has Rheumatoid Arthritis (RA)
    • Patient has Psoriatic Arthritis
    • Patient has Ankylosing Spondylitis
    • Patient has Plaque Psoriasis
Please include the following information when submitting a referral for Rapid Infliximab (Remicade, Inflectra, Renflexis):
  • Result of Tuberculosis (TB) skin/ lab testing
  • Hepatitis B status & date
  • Patients current weight and height
  • Clinicals to support one or more of the following:
    • Patient has active moderate to severe Crohn’s disease (CD)
    • Patient has active moderately to severely active Ulcerative Colitis (UC)
    • Patient has Rheumatoid Arthritis (RA)
    • Patient has Psoriatic Arthritis
    • Patient has Ankylosing Spondylitis
    • Patient has Plaque Psoriasis
Please include the following information when submitting a referral for Rituximab (Rituxan, Truxima, Ruxience):
  • Patient's current weight and height
  • Hepatitis B status & date
  • Most recent CBC results
  • Patient has moderately to severely active rheumatoid arthritis (RA) and is currently taking methotrexate
Please include the following information when submitting a referral for rozanolixizumab-noli (Rystiggo):
  • Supporting clinicals that show the patient has generalized myasthenia gravis (gMG) and is anti-acetylcholine receptor (AChR) or anti-muscle-specific tyrosine kinase (MuSK) antibody positive.
Please include the following information when submitting a referral for Saphnelo:
  • Clinical information that supports the diagnosis of an adult patient with moderate to severe systemic lupus erythematosus (SLE)
Please include the following information when submitting a referral for Simponi Aria:
  • Results of a recent tuberculosis (TB) skin/lab testing
  • Patient's current weight and height
  • Clinicals to support one or more of the following:
    • Patient has moderately to severely active rheumatoid arthritis (RA) and is taking methotrexate
    • Patient has active psoriatic arthritis
    • Patient has active ankylosing spondylitis
Please include the following information when submitting a referral for Skyrizi:
  • Result of Tuberculosis (TB) skin/ lab testing
  • Baseline Liver Enzymes and Bilirubin
Please include the following information when submitting a referral for Soliris:
  • Patient has been immunized with meningococcal vaccines at least 2 weeks prior to administering the first dose of Soliris
  • Clinicals to support one or more of the following:
    • Patient has Paraxysmal Nocturnal Hemoglobinuria (PNH)
    • Patient has atypical Hemolytic Uremic Syndrome (aHUS)
    • Patient has anti-AChR+ generalized Myasthenia Gravis (gMG)
    • Patient has anti-AQP4 Antibody-Positive Neuromyelitis Optica Spectrum Disorder (NMOSD)
Please include the following information when submitting a referral for Solu-Medrol:
Please include the following information when submitting a referral for Spevigo:
  • Results of recent Tuberculosis (TB) skin/ lab testing
Please include the following information when submitting a referral for Stelara IV:
  • Result of Tuberculosis (TB) skin/lab testing
  • Patients current weight and height
  • Patient has active moderate to severe Crohn’s disease (CD)
    • Who has failed or was intolerant to treatment with immunomodulators or corticosteroids but never failed treatment with a tumor necrosis factor blocker
    • Or failed or were intolerant to treatment with one or more TNF blockers
  • Patient has active psoriatic arthritis
  • Patient has moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy
Please include the following information when submitting a referral for Stelara SQ:
  • Results of a recent tuberculosis (TB) skin/lab testing
  • Patient's current weight and height
  • For Crohn's patients, include date of induction dose given
  • Clinicals to support one or more of the following:
    • Patient has moderately to severely active Crohn’s disease (CD) and evidence to support one or more of the following:
      • Failed or was intolerant to treatment with immunomodulators or corticosteroids but never failed treatment with a tumor necrosis factor blocker OR
      • Failed or was intolerant to treatment with one or more TNF blockers
  • Patient has active psoriatic arthritis
  • Patient has moderate to severe plaque psoriasis who is a candidate for phototherapy or systemic therapy
Please include the following information when submitting a referral for Tepezza:
  • List of current medications and surgical procedures used to treat condition
  • Patient's current weight and height
  • T3/T4 Lab
  • Patient's Clinical Activity Score (CAS) - Download Tepezza CAS Form
  • Clinicals to support patient has Thyroid Eye Disease (TED)

To download the Horizon Patient Enrollment Form, please select your state:

  • Arkansas
  • California
  • Connecticut
  • Florida
  • Illinois
  • Indiana
  • Kansas
  • Missouri
  • North Carolina
  • Ohio
  • Pennsylvania
  • Tennessee
Please include the following information when submitting a referral for Tezspire:
  • Clinicals that support severe asthma
Please include the following information when submitting a referral for Thyrogen:
  • Patient has a history of thyroid cancer who has previously undergone thyroidectomy
Please include the following information when submitting a referral for Tysabri:
  • Clinicals to support one or more of the following:
    • Patient has relapsing-remitting multiple sclerosis (RRMS)
    • Patient has moderately to severely active Crohn’s disease (CD) who had an inadequate response to, or was unable to tolerate, conventional CD therapies and inhibitors of TNF
    • JCV results
Please include the following information when submitting a referral for Ultomiris:
  • Patient has been immunized with meningococcal vaccines at least 2 weeks prior to administering the first dose of Ultomiris
  • Clinicals to support one or more of the following:
    • Patient has Paraxysmal Nocturnal Hemoglobinuria (PNH)
    • Patient has atypical Hemolytic Uremic Syndrome (aHUS)
Please include the following information when submitting a referral for Uplizna:
  • Hepatitis B virus, quantitative serum immunoglobulins, and tuberculosis screening is required before the first dose.
Please include the following information when submitting a referral for Venofer:
  • Most recent lab results
  • Patient has iron deficiency anemia, chronic kidney disease and is over 2 years of age
Please include the following information when submitting a referral for Vyepti:
  • Clinicals to support an indication for the preventive treatment of migraines in adult patients
  • Patient has a history of migraines and has been on 2 oral preventatives and has experienced 4 or more migraines within a month period
Please include the following information when submitting a referral for Vyvgart:
  • Supporting clinicals that show the patient is AChR antibody positive
Please include the following information when submitting a referral for Vyvgart Hytrulo:
  • Supporting clinicals that show the patient has generalized myasthenia gravis (gMG) and is anti-acetylcholine receptor (AChR) antibody positive.
Please include the following information when submitting a referral for Xolair:
  • Patient’s current weight and height
  • IgE Lab results
  • FEV1 test results showing demonstrated airflow limitation: FEV1 less than 80%
  • Clinicals to support one or more of the following:
    • Patient has moderate to severe persistent asthma, is 6 years of age or older, has had a positive skin test or in vitro reactivity to a perennial aeroallergen and whose symptoms are inadequately controlled with inhaled corticosteroids
    • Patient has chronic idiopathic urticaria, is 12 years of age or older and remains symptomatic despite H1 antihistamine treatment
    • Nasal polyps in adult patients 18 years of age and older with inadequate response to nasal corticosteroids, as add-on maintenance treatment
    • patients 1 year of age or older with an IgE-mediated food allergy for the reduction of allergic reactions (Type I), including anaphylaxis, that may occur with accidental exposure to one or more foods