To refer a patient, please choose the appropriate plan of treatment from the list below and fax to 1‐866‐872‐8920, or call 1‐800‐809‐1265 for assistance. Providers can also submit a plan of treatment electronically using the “Upload POTs/Referral Docs” button below.

In addition to a signed and dated Plan of Treatment, please provide the following information to expedite the referral process:

• Diagnosis / ICD-10 diagnosis code
• Most recent history and physical including:
  • Current / complete medication list
  • Most recent office visit notes
  • Past medical history
  • Tried and failed therapies
  • Allergy history
  • Current height / weight
• Drugs and dosing schedule, including last dose and next dose due if applicable
• Most recent lab/test results clinically relevant to therapy. For example: Hep B panel, Calcium and CrCl, PPD Test, etc.
• Insurance information

• Actemra Plan of Treatment Adult Rheumatology
• Actemra Plan of Treatment Pediatric Rheumatology
• Adakveo Plan of Treatment
• Albumin Standard Plan of Treatment
• Alpha 1-Antitrypsin Deficiency Standard Plan of Treatment
• Amvuttra Plan of Treatment
• Antibiotics (Anti-infective) Standard Plan of Treatment (AIC)
• Anti-Infective (Antibiotics, Antivirals, and Antifungals) Plan of Treatment (Home Infusion)
• Aredia (pamidronate disodium) Standard Plan of Treatment
• Avsola Dermatology Plan of Treatment
• Avsola Gastroenterology Plan of Treatment
• Avsola Rheumatology Plan of Treatment
• Benlysta Standard Plan of Treatment
• Boniva (ibandronate sodium) Standard Plan of Treatment
• Cabenuva Standard Plan of Treatment
• Cerezyme POT ICD 10 102215
• Cimzia Plan of Treatment for Gastroenterology
• Cimzia Plan of Treatment for Rheumatology
• Cinqair Plan of Treatment
• Crysvita Plan of Treatment for Adult Patients
• Crysvita Plan of Treatment for Pediatric Patients
• Cytoxan (Cyclophosphamide) Plan of Treatment (Not available in all locations)
• Dalvance Plan of Treatment
• Elaprase POT ICD 10 102215
• Entyvio Gastroenterology Plan of Treatment
• Evenity Standard Plan of Treatment
• Evkeeza Standard Plan of Treatment
• Fabrazyme Standard Plan of Treatment
• Fasenra Standard Plan of Treatment
• Generic or Blank Plan of Treatment
• Givlaari Plan of Treatment
• Hydration Standard Plan of Treatment
• HyQvia Standard Plan of Treatment
• Ilumya Plan of Treatment
• Immunoglobulin (IVIG) Plan of Treatment
• Immunoglobulin Subcutaneous Standard Plan of Treatment
• Inflectra Dermatology Plan of Treatment
• Inflectra Gastroenterology Plan of Treatment
• Inflectra Rheumatology Plan of Treatment
• Intralipids Plan of Treatment
• Iron Standard Plan of Treatment
• Kimyrsa Standard Plan of Treatment
• Krystexxa Standard Plan of Treatment
• Lemtrada Plan of Treatment (Not available in all locations)
• Leqvio Plan of Treatment
• Levothyroxine Standard Plan of Treatment
• Line Care Alteplase (Cathflo Activase) Standard Plan of Treatment (AIC)
• Cathflo Plan of Treatment (Home Infusion)
• Line Care Standard Plan of Treatment (AIC)
• Line Care Plan of Treatment (Home Infusion)
• Lumizyme Plan of Treatment ICD 10 102215
• Magnesium Standard Plan of Treatment
• Nexviazyme Standard Plan of Treatment
• Nucala Plan of Treatment for Asthma
• Nucala Plan of Treatment for EGPA
• Nucala Standard Plan of Treatment for Nasal Polyps
• Nulojix Standard Plan of Treatment
• Ocrevus Plan of Treatment
• Onpattro Plan of Treatment
• Orbactiv Standard Plan of Treatment
• Orencia Adult Rheumatology Plan of Treatment
• Orencia Pediatric Rheumatology Plan of Treatment
• Prolia Standard Plan of Treatment
• Radicava Plan of Treatment
• Reclast (zoledronic acid) Standard Plan of Treatment
• Remicade Dermatology Plan of Treatment
• Remicade Gastroenterology Plan of Treatment
• Remicade Rheumatology Plan of Treatment
• Renflexis Dermatology Plan of Treatment
• Renflexis Gastroenterology Plan of Treatment
• Renflexis Rheumatology Plan of Treatment
• Riabni Plan of Treatment for GPA-MPA
• Riabni Plan of Treatment for Rheumatology
• Rituxan Plan of Treatment for GPA-MPA
• Rituxan Plan of Treatment for Rheumatology
• Ruxience Plan of Treatment for GPA-MPA
• Ruxience Plan of Treatment for Rheumatology
• Saphnelo Standard Plan of Treatment
• Simponi ARIA Standard Plan of Treatment
• Skyrizi Plan of Treatment for Gastroenterology
• Soliris Plan of Treatment for aHUS
• Soliris Plan of Treatment for aHUS for Pediatric Patients
• Soliris Plan of Treatment for Myasthenia Gravis
• Soliris Plan of Treatment for NMOSD
• Soliris Plan of Treatment for PNH
• Solumedrol (Methylprednisolone) Plan of Treatment (AIC)
• Solumedrol Plan of Treatment (Home Infusion)
• Standing Adverse Reaction Orders
• Stelara Plan of Treatment for Rheumatology and Dermatology
• Stelara Plan of Treatment for Gastroenterology
• Tepezza Plan of Treatment
• Tezspire Plan of Treatment
• Trogarzo Plan of Treatment
• Truxima Plan of Treatment for GPA-MPA
• Truxima Plan of Treatment for Rheumatology
• Tysabri Standard Plan of Treatment
• Ultomiris Plan of Treatment
• Uplizna Plan of Treatment
• Vimizim Plan of Treatment
• Vpriv Plan of Treatment
• Vyepti Plan of Treatment
• Vyvgart Plan of Treatment
• Xolair Standard Plan of Treatment for Asthma
• Xolair Standard Plan of Treatment for Nasal Polyps
• Xolair Standard Plan of Treatment for Urticaria
• Xgeva Plan of Treatment
• Zemdri Plan of Treatment