Referral forms
To begin the referral process, find the referral form by specialty condition and product name in the list below. Then, fill in the required prescription and enrollment information and fax it to us at the number printed on the form. Referral form submissions must be sent from licensed prescribers. We are committed to providing the best care for your patients.
Search by the first letter of the specialty condition that interests you.
A
B
- Advate™ (antihemophilic factor (recombinant))
- Adynovate®(antihemophilic factor [recombinant], PEGylated)
- Afstyla® (antihemophilic factor [recombinant], single chain)
- Alphanate® (antihemophilic factor/VWF complex [human])
- AlphaNine® SD (coagulation factor IX [human])
- Alprolix™ (coagulation factor IX [recombinant], fc fusion protein)
- Amicar® (aminocaproic acid)
- ATryn® (antithrombin)
- Bebulin® (coagulation factor IX complex)
- BeneFIX® (coagulation factor IX [recombinant])
- Corifact® (factor XIII concentrate)
- Cyklokapron® (tranexamic acid)
- Eloctate™ (anitemophilic factor [recombinant], fc fusion protein)
- Esperoct® (antihemophilic factor (recombinant))
- Feiba® (anti-inhibitor coagulant complex)
- Helixate® FS (antihemophilic factor [recombinant])
- Hemlibra® (emicizumab-kxwh [recombinant])
- Hemofil® M (antihemophilic factor [human])
- Humate-P® (antihemophilic factor VIII,von willebrand factor)
- Idelvion® (coagulation factor IX [recombinant], albumin fusion protein)
- Ixinity® (coagulation factor IX [recombinant])
- Jivi® (antihemophilic factor [recombinant] PEGylated-aucl)
- Koate® (antihemophilic factor [human])
- Kogenate® FS (antihemophilic factor [recombinant])
- Kovaltry® (antihemophilic factor [recombinant])
- Lysteda® (tranexamic acid)
- Monoclate P® (antihemophilic factor VIII)
- Mononine® (coagulation factor IX)
- NovoSeven® RT (coagulation factor VIIa [recombinant])
- NovoEight® (antihemophilic factor [recombinant])
- Nuwiq® (antihemophilic factor [recombinant])
- Profilnine® SD (coagulation factor IX complex)
- Rebinyn® (coagulation factor IX (recombinant), GlycoPEGylated)
- Recombinate™ (antihemophilic factor [recombinant])
- RiaSTAP™ (fibrinogen concentrate [human])
- Rixubis (coagulation factor IX [recombinant])
- Sevenfact® (coagulation factor VIIa [recombinant]
- Stimate® (desmopressin acetate)
- Tretten® (coagulation factor XIII a-subunit [recombinant])
- Wilate® (von willebrand factor,factor VIII complex)
- Xyntha™ (antihemophilic factor [Recombinant], plasma/albumin-free)
- Aranesp® (darbepoetin alfa)
- Epogen® (epoetin alfa)
- Fulphila™ (pegfilgrastim-jmdb)
- Granix® (tbo-filgrastim)
- Leukine® (sargramostim)
- Neulasta® (pegfilgrastim)
- Neulasta® (pegfilgrastim) - Onpro® kit
- Neupogen® (filgrastim)
- Nivestym® (filgrastim-aafi)
- Nyvepria™ (pegfilgrastim-apgf)
- Procrit® (epoetin alfa)
- Retacrit™ (epoetin alfa-ebpx)
- Udenyca™ (pegfilgrastim-cbqv)
- Zarxio® (filgrastim-sndz)
- Ziextenzo™ (pegfilgrastim-bmez)
C
- Abraxane® (paclitaxel protein-bound)
- Afinitor® (everolimus)
- Alecensa® (alectinib)
- Arranon® (nelarabine)
- Arzerra® (ofatumumab)
- Avastin® (bevacizumab)
- Bendeka® (bendamustine HCl)
- Besponsa® (inotuzumab ozogamicin)
- Bosulif® (bosutinib)
- Cabometyx™ (cabozantinib)
- Cotellic™ (cobimetinib)
- Darzalex™ (daratumumab)
- Dacogen® (decitabine)
- Daurismo™ (glasdegib)
- deferiprone
- Doptelet® (avatrombopag)
- Eligard® (leuprolide acetate)
- Empliciti™ (elotuzumab)
- Enhertu® (fam-trastuzumab deruxtecan-nxki)
- Erbitux® (cetuximab)
- Erivedge™ (vismodegib)
- Farydak® (panobinostat)
- Faslodex® (fulvestrant)
- Firmagon® (degarelix)
- Folotyn™ (pralatrexate)
- Fulphila™ (pegfilgrastim-jmdb)
- Gazyva™ (obinutuzumab)
- Gilotrif™ (afatinib)
- Gleevec® (imatinib mesylate)
- Gavreto™ (pralsetinib)
- Halaven® (eribulin mesylate)
- Herceptin® (trastuzumab)
- Hycamtin® Oral (topotecan)
- Ibrance® (palbociclib)
- Imfinzi® (durvalumab)
- Inlyta® (axitinib)
- Iressa® (axitinib)
- Istodax® (romidepsin)
- Ixempra™ (ixabepilone)
- Jevtana® (cabazitaxel)
- Kadcyla™ (ado-trastuzumab emtansine)
- Kanjinti™ (trastuzumab-anns)
- Keytruda® (pembrolizumab)
- Kisqali® (ribociclib)
- Lartruvo™ (olaratumab)
- Lenvima® (lenvatinib)
- Lonsurf (trifluridine and tipiracil)
- Lorbrena® (lorlatinib)
- Lupron Depot® (leuprolide acetate for depot suspension)
- Lynparza™ (olaparib)
- Mekinist™ (trametinib)
- Mozobil™ (plerixafor)
- Mulpleta® (lusutrombopag)
- Mvasi™ (bevacizumab-awwb)
- Mylotarg™ (gemtuzumab ozogamicin)
- Nerlynx™ (neratinib)
- Ninlaro® (ixazomib)
- Nplate™ (romiplostim)
- Odomzo® (sonidegib)
- Opdivo® (nivolumab)
- Perjeta™ (pertuzumab)
- Piqray® (alpelisib)
- Polivy™ (polatuzumab vedotin-piiq)
- Pomalyst® (pomalidomide)
- Proleukin® (aldesleukin)
- Promacta® (Thrombocytopenia – Chronic Immune)
- Retevmo™ (selpercatinib)
- Revlimid® (lenalidomide)
- Rituxan® (rituximab)
- Rubraca® (rucaparib)
- Rybrevant™ (amivantamab-vmjw)
- Rydapt® (midostaurin)
- Sandostatin LAR® (octreotide acetate)
- Sandostatin® (octreotide)
- Somavert® (pegvisomant)
- Sprycel® (dasatinib)
- Stivarga® (regorafenib)
- Sutent® (sunitinib malate)
- Sylatron™ (peginterferon alfa-2b)
- Tabrecta™ (capmatinib)
- Tafinlar® (dabrafenib)
- Tagrisso® (osimertinib)
- Talzenna® (talazoparib)
- Tarceva® (erlotinib)
- Targretin® (bexarotene)
- Tasigna® (nilotinib)
- Tecentriq™ (atezolizumab)
- Temodar® IV (temozolomide)
- Temodar® Oral (temozolomide)
- Thalomid® (thalidomide)
- Tivdak™ (tisotumab vedotin-tftv)
- Torisel® (temsirolimus)
- Treanda® (bendamustine hydrochloride)
- Tykerb® (lapatinib)
- Valchlor® (mechlorethamine)
- Vantas® (histrelin implant)
- Vectibix® (panitumumab)
- Velcade® (bortezomib)
- Vidaza® (azacitidine)
- Vitrakvi® (larotrectinib)
- Vizimpro® (dacomitinib)
- Votrient™ (pazopanib)
- Xalkori® (crizotinib)
- Xeloda® (capecitabine)
- Xgeva™ (denosumab)
- Xtandi® (enzalutamide)
- Yervoy™ (ipilimumab)
- Yonsa® (abiraterone acetate)
- Zaltrap® (ziv-aflibercept)
- Zelboraf™ (vemurafenib)
- Zoladex® (goserelin)
- Zolinza® (vorinostat)
- Zykadia™ (ceritinib)
- Zytiga® (abiraterone acetate)
- Bethkis® (tobramycin inhalation solution)
- Cayston® (aztreonam inhalation solution)
- Kalydeco™ (ivacaftor)
- Kitabis Pak™ (tobramycin inhalation solution)
- Orkambi® (lumacaftor/ivacaftor)
- Pulmozyme® (dornase alfa)
- Symdeko® (tezacafter/ivacaftor)
- Tobi Podhaler™ (tobramycin inhalation powder)
- Tobi® (tobramycin)
- Trikafta™ (elexacaftor, ivacaftor and tezacaftor)
D
E
- Egrifta® (tesamorelin for injection)
- Kuvan® (sapropterin dihydrochloride)
- Lupaneta Pack™ (leuprolide acetate for depot suspension and norethindrone acetate tablets)
- Lupron Depot-Ped® (leuprolide acetate)
- Myalept® (metreleptin)
- Natpara® (parathyroid hormone)
- Palynziq™ (pegvaliase-pqpz)
- Samsca® (tolvaptan)
- Sandostatin® (octreotide acetate)
- Sandostatin LAR® (octreotide acetate)
- Serostim® (somatropin)
- Somatuline® Depot (lanreotide)
- Somavert® (pegvisomant)
- Supprelin® LA (histrelin acetate)
- Zorbtive® (somatropin [rDNA origin] for injection)
- Aldurazyme® (laronidase)
- Cerdelga® (eliglustat)
- Cerezyme® (imiglucerase for injection)
- Elaprase® (idursulfase)
- Elelyso® (taliglucerase alfa)
- Fabrazyme® (agalsidase beta)
- Galafold™ (migalastat)
- Kanuma® (sebelipase alfa)
- Lumizyme® (alglucosidase alfa)
- Mepsevii™ (vestronidase alfa)
- Naglazyme® (galsulfase)
- Vimizim® (elosulfase alfa)
- Vpriv® (velaglucerase alfa)
- Zavesca® (miglustat)
G
- Genotropin® (somatropin, rDNA origin) - Pediatric Indication
- Humatrope® (somatropin, rDNA origin) - Pediatric Indication
- Increlex® (mecasermin, rDNA origin) - Pediatric Indication
- Norditropin® (somatropin, rDNA origin) – Adult Indication
- Norditropin® (somatropin, rDNA origin) – Pediatric Indication
- Nutropin® (somatropin, rDNA origin) – Adult Indication
- Nutropin® (somatropin, rDNA origin) – Pediatric Indication
- Omnitrope® (somatropin, rDNA origin) – Adult Indication
- Omnitrope® (somatropin, rDNA origin) – Pediatric Indication
- Saizen® (somatropin) – Adult Indication
- Saizen® (somatropin) – Pediatric Indication
- Serostim® (somatropin [rDNA origin] for injection)
- Skytrofa® (lonapegsomatropin-tcgd)
- Supprelin® LA (histrelin acetate)
- Zomacton® (somatropin, rDNA origin) – Pediatric Indication
- Zorbtive® (somatropin [rDNA origin] for injection)
H
- Copegus® (ribavirin)
- Daklinza™ (daclatasvir)
- Epclusa® (sofosbuvir 400 mg/velpatasvir 100 mg)
- Harvoni® (ledipasvir and sofosbuvir tablets)
- Intron® A (interferon alfa-2b)
- Moderiba™ (ribavirin, USP)
- Mavyret™ (glecaprevir/pibrentasvir)
- Olysio™ (simeprevir)
- Promacta® (thrombocytopenia)
- Rebetol® (ribavirin)
- Ribapak® (ribavirin)
- Ribasphere® (ribavirin)
- Ribavirin® (ribavirin)
- Sovaldi™ (sofosbuvir)
- Technivie™ (ombitasvir, paritaprevir, and ritonavir tablets)
- Viekira XR™ (dasabuvir, ombitasvir, paritaprevir, and ritonavir tablets)
- Vosevi® (sofosbuvir/velpatasvir/voxilaprevir)
- Zepatier® (elbasvir and grazoprevir)
- Aptivus® (tipranavir)
- Atripla® (efavirenz, emtricitabine, and tenofovir)
- Cimduo™ (lamivudine and tenofovir disoproxil fumarate)
- Combivir® (lamivudine and zidovudine)
- Complera® (emtricitabine, rilpivirine, and tenofovir)
- Crixivan® (indinavir sulfate)
- Descovy® (emtricitabine and tenofovir alafenamide)
- Edurant® (rilpivirine)
- Egrifta® (tesamorelin for injection)
- Emtrivia® (emtricitabine)
- Epivir® (lamivudine)
- Epzicom® (abacavir and lamivudine)
- Evotaz™ (atazanavir/cobicistat)
- Fuzeon® (enfuvirtide)
- Genvoya® (elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide)
- Intelence® (etravirine)
- Invirase® (saquinavir)
- Isentress® (raltegravir)
- Kaletra® (lopinavir and ritonavir)
- Lexiva® (fosamprenavir)
- Norvir® (ritonavir)
- Odefsey® (emtricitabine, rilpivirine, tenofovir alafenamide)
- Prezcobix® (darunavir 800 mg/cobicistat 150 mg)
- Prezista® (darunavir)
- Rescriptor® (delavirdine)
- Retrovir® (zidovudine)
- Reyataz® (atazanavir)
- Rukobia (fostemsavir)
- Selzentry® (maraviroc)
- Serostim® (somatropin)
- Stribild® (cobicistat, elvitegravir, emtricitabine, and tenofovir)
- Sustiva® (efavirenz)
- Temixys® (lamivudine and tenofovir disoproxil fumarate)
- Triumeq® (abacavir, dolutegravir, and lamivudine)
- Trizivir® (abacavir, lamivudine, and zidovudine)
- Trogarzo™ (Ibalizumab-uiyk)
- Truvada® (emtricitabine and tenofovir)
- Tybost™ (cobicistat)
- Videx® (didanosine)
- Videx EC® (didanosine)
- Viramune XR® (nevirapine)
- Viread® (tenofovir)
- Vitekta™ (elvitegravir)
- Zerit® (stavudine)
- Ziagen® (abacavir)
I
- Actimmune® (interferon gamma-1b)
- Cytogam® (cytomegalovirus immune globulin)
- Gammagard® Liquid (immune globulin 10%)
- Gammagard S/D (immune globulin IgGA,1 mcg/mL)
- Gammaked® (immune globulin 10%)
- Gamunex® - C (immune globulin 10%)
- HyperRHO® S/D Rho(D) (immune globulin)
- MICRhoGAM® (immune globulin)
- Octagam® (immune globulin 5, 10%)
- Panzyga (immune globulin intravenous, human - ifas)
- Privigen™ (immune globulin 10%)
- RhoGAM® (Rho(D) immune globulin)
- Rhophylac® (Rho(D) immune globulin)
- WinRho® SDF (Rho(D) immune globulin)
- Cuvitru™ (immune globulin 20% subcutaneous)
- Gammagard® Liquid (immune globulin 10%)
- Gammaked® (immune globulin 10% )
- Gamunex®-C (immune globulin 10%)
- Hizentra™ (immune globulin 20% subcutaneous)
- HyQvia (immune globulin Infusion 10% (Human) with Recombinant Human Hyaluronidase)
- Xembify® (immune globulin subcutaneous human–klhw)
- Cetrotide® (cetrorelix acetate for injection)
- Crinone® (progesterone gel)
- Endometrin® (progesterone)
- Follistim AQ® (follicle stimulating hormone)
- Ganirelix (ganirelix acetate)
- Gonal-F® (follitropin alfa for injection)
- Leuprolide Acetate
- Menopur® (menotropins injection)
- Novarel® (chorionic gonadatropin)
- Ovidrel® (choriogonadotropin alfa injection)
- Pregnyl® (chorionic gonadatropin)
M
- Acthar H.P. Gel® (repository corticotropin injection)
- Apokyn® (apomorphine hydrochloride injection)
- Arcalyst® (rilonacept)
- ATryn® (antithrombin)
- Botox® (onabotulinumtoxinA)
- Carbaglu® (carglumic acid)
- Duopa™ (carbidopa/levodopa)
- Dysport® (abobotulinumtoxinA)
- Endari® (L-glutamine oral powder)
- Gattex® (teduglutide [rDNA origin])
- Hetlioz® (tasimelteon)
- Ilaris® (canakinumab)
- Krystexxa® (pegloticase)
- Leuprolide Acetate
- Makena™ (hydroxyprogesterone caproate injection)
- Myobloc® (rimabotulinumtoxinB)
- Nuplazid™ (pimavanserin)
- Ocaliva™ (obeticholic acid)
- Procysbi™ (cysteamine bitartrate)
- Prothelial™ (sucralfate)
- Purified Cortrophin Gel™ (repository corticotropin)
- Pyrimethamine
- Qutenza® (capsaicin)
- Sabril® (vigabatrin)
- Sandostatin® (octreotide acetate)
- Sandostatin LAR® (octreotide acetate)
- Soliris® (eculizumab)
- Sublocade™ (buprenorphine)
- Vivitrol® (naltrexone)
- Xenazine® (tetrabenazine)
- Xeomin® (incobotulinumtoxinA)
- Xiaflex® (collagenase clostridium histolyticum)
- Xipere™ (triamcinolone acetonide injectable suspension)
- Zorbtive® (somatropin [rDNA origin] for injection)
- Ampyra® (dalfampridine)
- Aubagio® (teriflunomide)
- Avonex® (interferon beta_1a)
- Betaseron® (interferon beta_1b)
- Copaxone® (glatiramer acetate)
- Extavia® (interferon beta_1b)
- Gilenya® (fingolimod)
- Glatopa® (glatiramer acetate)
- Kesimpta® (ofatumumab)
- Lemtrada® (alemtuzumab)
- Mavenclad® (cladribine)
- Mayzent® (Siponimod)
- Novantrone (mitoxantrone)
- Ocrevus™ (ocrelizumab)
- Plegridy® (peginterferon beta_1a)
- Rebif® (interferon beta_1a)
- Tecfidera® (dimethyl fumarate)
- Tysabri® (natalizumab)
- Uplizna® (inebilizumab injection)
- Vumerity™ (diroximel fumarate)
- Zeposia® (ozanimod)
N
- Aduhelm™ (aducanumab)
- Austedo® (deutetrabenazine)
- Botox® (onabotulinumtoxinA)
- Dysport® (abobotulinumtoxinA)
- Enspryng™ (satralizumab-mwge)
- Epidiolex® (cannabidiol)
- Myobloc® (rimabotulinumtoxinB)
- Nuplazid™ (pimavanserin)
- Northera™ (droxidopa)
- Sublocade™ (buprenorphine)
- Sabril® (vigabatrin)
- Vivitrol® (naltrexone)
- Wakix® (pitolisant)
- Xenazine® (tetrabenazine)
- Xeomin® (incobotulinumtoxinA)
- Cuvitru™ (immune globulin 20% subcutaneous)
- Emflaza® (deflazacort)
- Gammagard® Liquid (immune globulin 10%)
- Gammaked® (immune globulin 10%)
- Gamunex® - C (immune globulin 10%)
- Hizentra™ (immune globulin 20% subcutaneous)
- Panzyga (immune globulin intravenous, human - ifas)
- Privigen™ (immune globulin 10%)
- Xembify® (immune globulin subcutaneous human–klhw)
O
- Durolane® (hyaluronic acid)
- Euflexxa® (hyaluronic acid)
- Gel_One® (cross_linked hyaluronate)
- Gelsyn_3™ (sodium hyaluronate)
- Hyalgan® (sodium hyaluronate)
- Hymovis® (hyaluronic acid)
- Monovisc® (hyaluronan)
- OrthoVisc® (hyaluronan)
- Otezla® (apremilast)
- Supartz® (sodium hyaluronate)
- Synvisc® (hylan G_F 20)
- Synvisc_One® (hylan G_F 20)
P
- Avsola™ (infliximab-axxq)
- Cimzia® (certolizumab)
- Cosentyx™ (secukinumab)
- Gengraf® (cyclosporine)
- Humira® (adalimumab)
- Ilumya™ (tildrakizumab-asmn)
- Otezla® (apremilast)
- Remicade® (infliximab)
- Renflexis® (infliximab-abda)
- Siliq™ (brodalumab)
- Skyrizi™ (risankizumab-rzaa)
- Stelara® (ustekinumab)
- Taltz® (Ixekizumab)
- Tremfya™ (guselkumab)
R
- Avsola™ (infliximab-axxq)
- Actemra® (tocilizumab)
- Arcalyst® (rilonacept)
- Benlysta® (belimumab)
- Cimzia® (certolizumab)
- Cosentyx™ (secukinumab)
- Enbrel® (etanercept)
- GenVisc 850® (sodium hyaluronate viscosup)
- Humira® (adalimumab)
- Ilaris® (canakinumab)
- Kineret® (anakinra)
- Krystexxa™ (pegloticase)
- Olumiant® (baricitinib)
- Orencia® (abatacept)
- Remicade® (infliximab)
- Renflexis® (infliximab-abda)
- Rinvoq™ (upadacitinib)
- Rituxan® (rituximab)
- Simponi Aria® (golimumab, self inject)
- TriVisc® (sodium hyaluronate)
- Xeljanz® (tofacitinib)
- Xiaflex® (collagenase clostridium histolyticum)