Download Actemra form here.

Required clinicals:

• Negative TB screen

• Demographics

• Labs & Tests Supporting Diagnoses

• Office/Progress Notes

Download Amvuttra order form here.

Chart Notes Supporting Diagnosis

• Genetic testing confirming TTR mutation

• OR biopsy results showing amyloid deposits

• Family history documentation (if relevant)

• Neuropathy symptoms (sensory, motor, autonomic)

• Functional impairment

• Progression over time

• Medication list

Prior Treatment History

• Previous therapies (Onpattro, Tegsedi)

• Why prior therapies were ineffective

• Why contraindicated or not tolerated

Baseline Assessments & Labs

• Vitamin A level (required)

• Neuropathy Impairment Score (NIS), if available

• PND score, if available

• Labs supporting systemic involvement

Download Benlysta order form here.

Chart Notes Supporting Diagnosis

• Confirmed diagnosis of SLE or Lupus Nephritis

• ANA, anti-dsDNA, complement levels (C3/C4)

• Urinalysis + proteinuria results (if nephritis)

• Symptom history + disease activity

• Medication list

• Failed or inadequate response to standard therapies

Treatment History

Most payers require failure of ≥2 standard therapies:

• Hydroxychloroquine

• Corticosteroids

• Methotrexate

• Azathioprine

• Mycophenolate (required for nephritis)

• Intolerance or contraindications documented

Labs & Diagnostics

• ANA, anti-dsDNA

• Complement levels

• ESR/CRP

• Urinalysis + protein/creatinine ratio (nephritis)

• Imaging or biopsy results (if relevant)

Download Briumvi order form here.

Chart Notes Supporting Diagnosis

• Confirmed diagnosis of Relapsing MS

• Neurology evaluation notes

• Documented relapses or progression

• MRI showing active lesions

• EDSS score (if available)

• Current medication list

Treatment History

• Prior DMTs (Ocrevus, Kesimpta, Tysabri, Tecfidera, Aubagio, Gilenya, Copaxone, Rebif, etc.)

• Why prior therapies were ineffective

• Why not tolerated

• Why contraindicated

• Steroid use for recent relapses

Required Labs & Screening

• Hepatitis B panel (HBsAg, anti-HBc)

• CBC

• CMP

• Immunoglobulin levels (if available)

• Pregnancy test (if applicable)

MRI Imaging

• Baseline MRI within last 12 months

• Reports showing active or progressing lesions

Download Cabenuva order form here.

Chart Notes Supporting Diagnosis

• Confirmed HIV-1 diagnosis

• Viral load + CD4 history

• Documentation of viral suppression (<200 copies/mL)

• No history of treatment failure

• No known/suspected resistance to cabotegravir or rilpivirine

• Current ART regimen + tolerance

• Medication list

Required Labs

• HIV-1 RNA viral load (must show suppression)

• CD4 count

• Hepatitis B screening

• Pregnancy test (if applicable)

• CMP (baseline liver function)

Treatment History

• Current ART regimen

• Duration of viral suppression

• Adherence history

• Intolerance/contraindications to oral regimens (if applicable)

Resistance Testing

• Genotype showing no resistance to integrase inhibitors

• No resistance to NNRTIs (rilpivirine class)

• If older results unavailable → Document no history of virologic failure

Download Entyvio order form here.

Chart Notes Supporting Diagnosis

• Endoscopy/colonoscopy results

• Pathology (if applicable)

• CRP, fecal calprotectin

• Symptom history + disease activity

• Current medication list

• Documentation of failure/intolerance/contraindication to:

  • Corticosteroids

  • Immunomodulators (AZA, 6-MP, MTX)

  • Anti-TNFs (Humira, Remicade)

Treatment History

• Dates, doses, outcomes of prior therapies

• Reasons for discontinuation

• Biologic failures or loss of response

• Step-therapy documentation

Required Clinical Data

• Recent labs

• Negative Hep B

• Imaging or endoscopy reports

Download Evenity order form here.

Chart Notes Supporting Diagnosis

• Documentation of postmenopausal status

• Fragility fracture history

• OR documentation of very low bone density

• Risk factors (age, fractures, steroids, etc.)

• Current medication list

Bone Density Results

• DEXA within last 24 months

• T-scores (lumbar spine, hip, femoral neck)

• Osteoporosis (T-score ≤ –2.5)

• OR osteopenia + fragility fracture

Treatment History

• Bisphosphonates (Fosamax, Boniva, Reclast)

• Prolia

• Forteo / Tymlos

• Why prior therapies were ineffective

• Why not tolerated

• Why contraindicated

Required Labs

• Calcium

• Vitamin D

• CMP (renal function)

Download Evkeeza order form here.

Chart Notes Supporting Diagnosis

• Documentation confirming HoFH

• Genetic testing OR clinical criteria

• Baseline LDL-C levels

• Cardiovascular disease history (if applicable)

• Current medication list

• Persistent elevated LDL-C despite therapy

Required Labs

• Fasting lipid panel

  • LDL-C

  • HDL

  • Triglycerides

  • Total cholesterol

• Labs showing inadequate LDL-C reduction

Treatment History

• Maximally tolerated statin

• Ezetimibe

• PCSK9 inhibitor (Repatha/Praluent)

• Why each was ineffective

• Why not tolerated

• Why contraindicated

Download Exdensur order form here.

Chart Notes Supporting Diagnosis

• Confirmed severe eosinophilic asthma

• Symptom history

• Exacerbation frequency (ER, steroids, hospitalizations)

• Current medication list

• Poor control despite high-intensity therapy

Required Labs

• Blood eosinophils ≥150–300 cells/µL (payer-specific)

• IgE level (if relevant)

• PFTs (if available)

Treatment History

• High-dose ICS + LABA

• Additional controllers (LAMA, leukotriene modifiers)

• Prior biologics (Nucala, Fasenra, Dupixent, Cinqair)

• Why prior therapies were ineffective

• Why not tolerated

• Why contraindicated

• Oral steroid dependence (if applicable)

• PFTs (FEV1, reversibility)

Required Diagnostics

For RMS

• MRI brain ± spine (baseline)

• CBC/CMP

For Crohn's

• CBC/CMP

• CRP ± fecal calprotectin

• Endoscopy/colonoscopy results

• CT/MR enterography (if available)

Treatment History (continued)

For RMS

• Prior DMTs listed (interferons, Copaxone, Tecfidera, Vumerity, Aubagio, Ocrevus, Kesimpta, etc.)

• Steroid use for relapses documented

For Crohn's

• Steroids

• Immunomodulators (AZA, 6-MP, MTX)

• Anti-TNFs (Humira, Remicade, Cimzia)

• Other biologics (Entyvio, Stelara, Skyrizi)

• JAK inhibitors (Xeljanz, Rinvoq)

For each therapy:

• Dose

• Dates

• Response

Download Fasenra order form here.

Chart Notes Supporting Diagnosis

• Confirmed diagnosis of severe eosinophilic asthma

• Symptom history

• Exacerbation frequency (ER visits, oral steroid bursts, hospitalizations)

• Current medication list

• Documentation of poor control despite high-intensity therapy

Required Labs

• Blood eosinophil count (≥150–300 cells/µL depending on payer)

• IgE level (if relevant to differential diagnosis)

• Pulmonary function tests (PFTs), if available

Treatment History

• High-dose ICS + LABA

• Additional controller therapies:

  • LAMA

  • Leukotriene modifiers

• Prior biologics (if any):

  • Nucala

  • Dupixent

  • Cinqair

• Why previous therapies were ineffective

• Why not tolerated

• Why contraindicated

Note: Most payers require failure of high-dose ICS/LABA + at least one additional controller.

Download Hyqvia order form here.

Chart Notes Supporting Diagnosis

• Detailed history & physical exam

• Documentation of recurrent or severe infections (sinusitis, pneumonia, otitis, bronchitis, etc.)

• Frequency, severity, and duration of infections

• Response (or lack of response) to antibiotics

• Specialist notes (immunology, hematology, neurology, rheumatology depending on indication)

• Current medication list

• Attempts to taper steroids or immunosuppressants (if applicable)

Required Diagnostic Testing

Payers require objective immune deficiency evidence.

For Primary Immunodeficiency (PID)

• IgG, IgA, IgM levels

• Vaccine titers (e.g., pneumococcal, tetanus)

• B-cell function testing (if available)

• Infection history documented clearly

For Secondary Immunodeficiency

• Underlying condition documented (CLL, lymphoma, immunosuppressive therapy, etc.)

• IgG level below payer threshold

• Recurrent infections documented

For CIDP / Neuromuscular Indications (rare for HYQVIA)

• EMG/NCS

• CSF protein

• Neurology evaluation

For ITP (if applicable)

• Platelet count

• Exclusion of secondary causes

For Other Indications (Dermatomyositis, GBS, etc.)

• Muscle biopsy

• CK

• EMG

• Disease-specific tests

Treatment History

Payers want to see that HYQVIA is medically necessary.

• Previous therapies tried (steroids, immunosuppressants, disease-specific treatments)

• Dates, doses, and outcomes

• Attempts to taper medications

• Failures, intolerance, or contraindications

• Prior IVIG or SCIG use (if applicable)

  • Response

  • Adverse effects

  • Access issues

Additional Payer Requirements

• Documentation that patient can self-administer or has caregiver support

• Weight for dosing

• Requested dose and frequency

• Site of care (home infusion, AIS, clinic)

• Insurance card front/back

Download Ilumya order form here.

Chart Notes Supporting Diagnosis

• Confirmed diagnosis of plaque psoriasis

• Description of lesions (location, severity, BSA %)

• Symptom history (itching, scaling, pain)

• Documentation of inadequate control with topical therapies

• Current medication list

Required Labs

• TB screening (Quantiferon or PPD)

• Baseline CBC/CMP (if available)

Treatment History

Prior therapies attempted:

• Topical steroids

• Vitamin D analogs

• Phototherapy

• Systemic agents (methotrexate, cyclosporine, acitretin)

• Other biologics (Humira, Stelara, Skyrizi, Tremfya, Cosentyx, etc.)

Why previous therapies were:

• Ineffective

• Not tolerated

• Contraindicated

Note: Most payers require failure of topical therapy + one systemic or phototherapy.

Download Imaavy order form here.

Chart Notes Supporting Diagnosis

• Confirmed diagnosis of moderately to severely active ulcerative colitis

• ICD-10 code documented (e.g., K51.90, K51.00, etc.)

• Recent chart notes supporting diagnosis

• Symptom history (bleeding, urgency, frequency, abdominal pain)

• Endoscopy/colonoscopy results

• Pathology report (if available)

• Mayo or partial Mayo score (if available)

• Documentation of steroid dependence (if applicable)

Required Labs & Clinical Data

• CRP

• Fecal calprotectin

• CBC

• CMP

• TB screening (Quantiferon or PPD)

• Hepatitis B panel (HBsAg, anti-HBc, anti-HBs)

Treatment History

Prior therapies attempted:

• Prior corticosteroid use

• Prior immunomodulators (azathioprine, 6-MP, methotrexate)

• Prior anti-TNFs (Humira, Remicade, Cimzia)

• Prior biologics (Entyvio, Stelara, Skyrizi)

• Prior JAK inhibitors (Xeljanz, Rinvoq)

• Documentation of failure, intolerance, or contraindication

Download the iron order form here.

Chart Notes Supporting Diagnosis

• Symptom history (fatigue, dyspnea, pica, etc.)

• Relevant comorbidities (CKD, IBD, bariatric surgery, pregnancy, HF)

• Current medication list

• Documentation of blood loss (if applicable)

Required Labs

• Hemoglobin / Hematocrit

• Ferritin

• Transferrin saturation (TSAT)

• Serum iron / TIBC

• CBC

Documentation of Oral Iron Trial OR Contraindication

• Dates + duration of oral iron therapy

• Dose/formulation

• Reason for discontinuation (GI intolerance, malabsorption, non-response)

• OR contraindication documented (IBD flare, gastric bypass, severe CKD, etc.)

Download IVIG order form here.

Chart Notes Supporting Diagnosis

• Detailed history & physical exam

• Documentation of recurrent or severe infections

• Specialist notes (neurology, hematology, immunology, rheumatology)

• Attempts to taper steroids or immunosuppressants (if applicable)

Required Diagnostic Tests

For Primary Immunodeficiency (PID)

• IgG, IgA, IgM levels

• Vaccine titers (e.g., pneumococcal)

• B-cell function testing

• Infection history

For CIDP / Neuromuscular Disorders

• EMG/NCS

• CSF protein

• Neurology evaluation

For ITP

• Platelet count

• Exclusion of secondary causes

For Other Indications (Dermatomyositis, GBS, etc.)

• Muscle biopsy

• CK

• EMG

• Other disease-specific tests

Note: Payers explicitly require diagnostic tests such as IgG levels, EMG, platelet counts, spinal fluid tests, and biopsy findings.

Treatment History

• Previous therapies tried (steroids, immunosuppressants, disease-specific treatments)

• Dates, doses, outcomes

• Attempts to taper medications

• Failures, intolerance, or contraindications

Download Kisunla order form here.

Clinical Documentation

• Diagnosis: Mild cognitive impairment due to AD or mild Alzheimer's dementia

• Cognitive testing: MMSE or MoCA

• Functional status: FAST score

• Rationale for therapy

• Documentation that ARIA risks were discussed

• CMS Registry Issue Number + date

Proof of Amyloid Pathology

• Amyloid PET positive

• OR CSF biomarkers consistent with AD

MRI (within 12 months)

• No superficial siderosis

• <4 microhemorrhages

• No hemorrhage >1 cm

• No high-risk cerebrovascular findings

ApoE ε4

• Testing offered (result if done)

Concomitant Alzheimer's Medications

• Stable dose ≥12 weeks

• OR treatment-naïve and will not start for 12 months

General Labs

• CBC

• CMP

• Recent H&P

• Medication list

Eligibility

• Age ≥60

• No alternative dementia diagnosis

• No TIA, stroke, or seizure in last 12 months

Download Krystexxa order form here.

Chart Notes Supporting Diagnosis

• Chronic uncontrolled gout

• Gouty arthritis and/or visible tophi

• Flare frequency

• Joint damage or imaging

• Functional limitations

Required Labs

• Serum uric acid (history + most recent)

• G6PD testing (mandatory)

• CBC/CMP

Treatment History

• Allopurinol

• Febuxostat

• Uricosurics

• Methotrexate (if part of regimen)

• Dose, dates, response, failure/intolerance

• Documentation that XOIs/uricosurics will be discontinued

Download Leqembi order form here.

Clinical Documentation

• Diagnosis: Mild cognitive impairment due to AD or mild Alzheimer's dementia

• Cognitive testing: MMSE or MoCA

• Functional status: FAST score

• Rationale for therapy

• Documentation that ARIA risks were discussed

• CMS Registry Issue Number + date

Proof of Amyloid Pathology

• Amyloid PET positive

• OR CSF biomarkers consistent with AD

MRI (within 12 months)

• No superficial siderosis

• <4 microhemorrhages

• No hemorrhage >1 cm

• No high-risk cerebrovascular findings

ApoE ε4

• Testing offered (result if done)

Concomitant Alzheimer's Medications

• Stable dose ≥12 weeks

• OR treatment-naïve and will not start for 12 months

General Labs

• CBC

• CMP

• Recent H&P

• Medication list

Eligibility

• Age ≥60

• No alternative dementia diagnosis

• No TIA, stroke, or seizure in last 12 months

Download Leqvio order form here.

Chart Notes Supporting Diagnosis

• Primary hyperlipidemia ± ASCVD

• Lipid history

• Family history (if FH suspected)

• Current medication list

• Persistent elevated LDL-C

Required Labs

• Fasting lipid panel (LDL-C, HDL, TG, TC)

• Labs within 6–12 months

• Genetic testing (optional)

Treatment History

• Maximally tolerated statin

• Ezetimibe

• PCSK9 inhibitors (if payer requires)

• Ineffective / not tolerated / contraindicated

ASCVD Risk Documentation

• MI, stroke, PAD, revascularization

• Diabetes, HTN, smoking

• Family history

• Provider risk assessment

Download Nucala order form here.

Chart Notes Supporting Diagnosis

• Confirmed diagnosis

• Symptom history

• Exacerbation frequency

• Current medication list

• Poor control despite high-intensity therapy

Required Labs

• Eosinophils ≥150–300

• IgE (if relevant)

• PFTs

Treatment History

• High-dose ICS + LABA

• Additional controllers

• Prior biologics: Fasenra, Dupixent, Cinqair

• Ineffective / not tolerated / contraindicated

Download Nulojix order form here.

Chart Notes Supporting Diagnosis

• Proof of kidney transplant

• Maintenance immunosuppression plan

• Rejection history

• Graft function (creatinine, eGFR)

• EBV-positive serology (mandatory)

Required Labs

• CMP

• CBC

• EBV IgG

• CMV status

• BK virus monitoring

Treatment History

• Current immunosuppressants

• Prior calcineurin inhibitors

• Reason for switching (nephrotoxicity, intolerance, poor graft function)

Download Ocrevus order form here.

Chart Notes Supporting Diagnosis

• Neurology notes confirming MS

• Symptom history

• MRI showing demyelinating lesions

• Relapse history

• Current medication list

Required Labs

• Hepatitis B panel

• CBC/CMP

• Pregnancy test (if applicable)

Treatment History

• Prior MS therapies (Tysabri, Tecfidera, Gilenya, Aubagio, Copaxone, Rebif, Kesimpta, etc.)

• Dose, dates, response, reason stopped

• Rationale for Ocrevus

Download Ocrevus Zunovo form here.

Chart Notes Supporting Diagnosis

• Neurology notes confirming MS

• Symptom history

• MRI showing demyelinating lesions

• Relapse history

• Current medication list

Required Labs

• Hepatitis B panel

• CBC/CMP

• Pregnancy test (if applicable)

Treatment History

• Prior MS therapies (Tysabri, Tecfidera, Gilenya, Aubagio, Copaxone, Rebif, Kesimpta, etc.)

• Dose, dates, response, reason stopped

• Rationale for Ocrevus

Download Omvoh form here.

Chart Notes Supporting Diagnosis

• Confirmed CD/UC

• Symptom history

• Endoscopy/colonoscopy findings

• Pathology

• Current medication list

• Inadequate control with standard therapies

Required Labs

• CRP

• Fecal calprotectin

• CBC/CMP

• TB screening

Treatment History

• Steroids

• Immunomodulators

• Anti-TNFs

• Other biologics

• JAK inhibitors

• Dose, dates, response, reason stopped

Download Onpattro order form here.

Required clinicals:

• Demographics

• Labs & Tests Supporting Diagnoses 

• Office/Progress Notes