Why Flourish?

Download Orencia order form here.

Indications payers recognize 

• RA, PsA, pJIA, aGVHD prophylaxis (HSCT) 

Rheumatoid Arthritis (RA) 

Required documentation 

• Diagnosis of moderately to severely active RA 

• Rheumatology prescriber 

• Prior therapy failure/intolerance: 

• Methotrexate (usually required) 

• ± Other csDMARDs (leflunomide, sulfasalazine) 

• Some plans require failure of one TNF inhibitor before Orencia 

• Current medication list 

Baseline labs 

• TB test 

• CBC/CMP 

• Hepatitis screening (payer‑driven) 

Psoriatic Arthritis (PsA) 

Required documentation 

• Active PsA confirmed by rheumatology 

• Prior therapy failure: 

• Methotrexate or other csDMARD 

• Often one biologic (TNF inhibitor or IL‑17/IL‑23) depending on formulary 

• Current medication list 

Baseline labs 

• TB test 

• CBC/CMP 

Polyarticular JIA (pJIA) 

Required documentation 

• Diagnosis by pediatric rheumatology 

• Prior csDMARD failure (MTX) 

• Sometimes prior biologic failure required 

• Current medication list 

Baseline labs 

• TB test 

• CBC/CMP 

aGVHD Prophylaxis (HSCT) 

Required documentation 

• HSCT from matched or 1‑allele mismatched unrelated donor 

• Transplant center prescriber 

• Must be used with calcineurin inhibitor + methotrexate 

• No active infection 

• Current medication list 

Baseline labs 

• TB test 

• Viral screening (EBV, CMV) 

• CBC/CMP 

Download Prolia & Biosimilar order form here

Indications payers recognize  

• Osteoporosis at high risk for fracture (postmenopausal women, men) 

• Glucocorticoid‑induced osteoporosis 

• Cancer‑therapy–associated bone loss (ADT in prostate cancer; AI in breast cancer) 

Typical PA requirements 

1. Diagnosis & fracture risk- DEXA within last 2 years 

• Documented osteoporosis (often: 

• T‑score ≤ −2.5, or 

• History of fragility fracture) 

• Or high fracture risk with osteopenia (T‑score between −1.0 and −2.5 plus risk factors). 

2. Prior therapy / step edits 

• Failure, intolerance, or contraindication to oral bisphosphonates (e.g., alendronate, risedronate) 

• Sometimes trial of IV zoledronic acid unless contraindicated (CKD, intolerance). 

3. Baseline labs & CKD assessment 

• Serum calcium, ± 25‑OH vitamin D, ± PTH 

• Renal function (SCr, eGFR) 

• In advanced CKD, documentation of CKD‑MBD evaluation and specialist oversight, per boxed warning.  

4. Supplementation & counseling 

• Plan for daily calcium and vitamin D 

• Dental evaluation often recommended (ONJ risk). 

5. Prescriber 

• Typically endocrinology, rheumatology, nephrology, or oncology; some plans allow PCP with strong documentation.

Download Reclast order form here.

Indications payers recognize 

• Osteoporosis at high risk for fracture (postmenopausal women, men) 

• Glucocorticoid‑induced osteoporosis 

• Paget’s disease of bone 

Typical PA requirements 

1. Diagnosis & fracture risk 

• Osteoporosis: 

• T‑score ≤ −2.5, or 

• History of fragility fracture 

• High‑risk osteopenia sometimes accepted (T‑score between −1.0 and −2.5 plus risk factors)C. 

• Paget’s disease: 

• Elevated ALP + characteristic radiographic findings + symptoms. 

2. Prior therapy / step edits 

• Often used as: 

• First‑line IV option when oral bisphosphonates are not tolerated or contraindicated, or 

• Step after oral failure/intolerance. 

• Some plans require: 

• Trial of oral alendronate/risedronate unless GI or adherence issues documented. 

3. Baseline labs & renal assessment 

• Serum creatinine / eGFR (must be ≥35 mL/min) 

• Serum calcium, ± 25‑OH vitamin D 

• For Paget’s: ALP and imaging documentation. 

4. Supplementation & counseling 

• Plan for calcium and vitamin D supplementation 

• Dental evaluation recommended (ONJ risk), especially in high‑risk patients. 

5. Prescriber 

• Typically endocrinology, rheumatology, nephrology, or primary care with clear documentation; Paget’s often managed by endocrinology/rheumatology. 

Download Remicade & Biosimilars order form here.

REMICADE / BIOSIMILARS  

Indications payers recognize 

• IBD (CD, UC) 

• RA, AS, PsA, PsO 

IBD (Crohn’s disease & Ulcerative colitis) 

Required documentation: 

• Confirmed diagnosis (endoscopy/biopsy). 

• Moderate–severe disease: 

• CD: CDAI/clinical criteria, fistulas, weight loss, anemia. 

• UC: Mayo/partial Mayo, bleeding, urgency, anemia. 

• Current medication list 

Prior therapy / step edits: 

• Failure/intolerance of: 

• Steroids (inadequate response or steroid‑dependence). 

• Immunomodulators (AZA, 6‑MP, MTX) in many plans. 

• Some payers require: 

• Trial/failure of another biologic depending on formulary (e.g., Humira, Entyvio, Stelara/Skyrizi for CD; Entyvio, Stelara, Omvoh for UC). 

Baseline labs: 

• CBC, CMP 

• TB test (IGRA/PPD) 

• Hep B panel often required. 

Prescriber: 

• Gastroenterologist. 

Rheumatoid arthritis (RA) 

Required documentation: 

• Moderately to severely active RA diagnosed by rheumatology. 

• Must be used with methotrexate (PI + payer). 

• Current medication list 

Prior therapy / step edits: 

• Failure/intolerance of: 

• Methotrexate (usually mandatory). 

• Often ≥1 other csDMARD (sulfasalazine, leflunomide). 

• Some plans require failure of another biologic (e.g., Humira/Enbrel) before Remicade. 

Baseline labs: 

• TB test 

• CBC/CMP 

• ± Hep B/C. 

Prescriber: 

• Rheumatologist. 

AS, PsA, Plaque Psoriasis 

Required documentation: 

• Diagnosis by rheumatology (AS/PsA) or dermatology (PsO). 

• Active disease with functional impairment or inadequate control on NSAIDs/DMARDs/topicals. 

• Current medication list 

Prior therapy / step edits: 

• AS: failure of NSAIDs, often trial of another TNF or IL‑17 agent. 

• PsA: failure of csDMARD (MTX) ± prior biologic. 

• PsO: failure of topicals + phototherapy ± systemic (MTX, cyclosporine, acitretin) before biologic. 

Baseline labs: 

• TB test 

• CBC/CMP 

• ± Hep B/C. 

Prescriber: 

• Rheumatology or dermatology. 

Download Rituxan & Biosimilars order form here.

Indications payers recognize 

• IBD (CD, UC) 

• RA, AS, PsA, PsO 

IBD (Crohn’s disease & Ulcerative colitis) 

Required documentation: 

• Confirmed diagnosis (endoscopy/biopsy). 

• Moderate–severe disease: 

• CD: CDAI/clinical criteria, fistulas, weight loss, anemia. 

• UC: Mayo/partial Mayo, bleeding, urgency, anemia. 

• Current medication list 

Prior therapy / step edits: 

• Failure/intolerance of: 

• Steroids (inadequate response or steroid‑dependence). 

• Immunomodulators (AZA, 6‑MP, MTX) in many plans. 

• Some payers require: 

• Trial/failure of another biologic depending on formulary (e.g., Humira, Entyvio, Stelara/Skyrizi for CD; Entyvio, Stelara, Omvoh for UC). 

Baseline labs: 

• CBC, CMP CBC/CMP (often requested) 

• TB test  

• ± Hep B (HBsAg, anti‑HBc ± anti‑HBs) (often required) 

• ± Hep C 

Prescriber: 

• Gastroenterologist 

Rheumatoid arthritis (RA) 

Required documentation: 

• Moderately to severely active RA diagnosed by rheumatology. 

• Must be used with methotrexate (PI + payer). 

• Current medication list 

Prior therapy / step edits: 

• Failure/intolerance of: 

• Methotrexate (usually mandatory). 

• Often ≥1 other csDMARD (sulfasalazine, leflunomide). 

• Some plans require failure of another biologic (e.g., Humira/Enbrel) before Remicade. 

Baseline labs: 

• TB test 

• CBC/CMP CBC/CMP (often requested) 

• ± Hep B (HBsAg, anti‑HBc ± anti‑HBs) 

Prescriber: 

• Rheumatologist. 

AS, PsA, Plaque Psoriasis 

Required documentation: 

• Diagnosis by rheumatology (AS/PsA) or dermatology (PsO). 

• Active disease with functional impairment or inadequate control on NSAIDs/DMARDs/topicals. 

• Current medication list 

Prior therapy / step edits: 

• AS: failure of NSAIDs, often trial of another TNF or IL‑17 agent. 

• PsA: failure of csDMARD (MTX) ± prior biologic. 

• PsO: failure of topicals + phototherapy ± systemic (MTX, cyclosporine, acitretin) before biologic. 

Baseline labs: 

• TB test 

• CBC/CMP (often requested) 

• ± Hep B (HBsAg, anti‑HBc ± anti‑HBs) 

Prescriber: 

• Rheumatology or dermatology. 

Download Saphnelo order form here.

Indication payers recognize 

• Moderate to severe SLE in adults on standard therapy, excluding severe active LN or CNS lupus. 

Typical PA requirements 

• Diagnosis & severity: 

• Rheumatology‑confirmed SLE with moderate–severe disease (clinical features, SLEDAI/BILAG or similar). 

• On standard therapy (steroids ± antimalarials ± immunosuppressants) with inadequate control or steroid‑dependence. 

• Prior therapy / step edits: 

• Failure/intolerance of: 

• Hydroxychloroquine 

• Systemic steroids (ongoing moderate–high dose or frequent flares) 

• Often one conventional immunosuppressant (AZA, MMF, MTX) 

• Some plans require trial/failure of Benlysta before Saphnelo, depending on formulary. 

• Baseline labs / screening: 

• CBC, CMP 

• Infection assessment (zoster history, chronic infections) 

• Vaccination status (esp. zoster, pneumococcal, influenza). 

• Exclusions (common PA language): 

• Severe active lupus nephritis or severe active CNS lupus 

• Concomitant other biologic for SLE. 

• Prescriber: 

• Rheumatologist almost universally required. 

Download Simponi Aria order form here.

Indications payers recognize 

• RA (adult, with MTX) 

• PsA (adult & pediatric ≥2 years) 

• AS (adult) 

• pJIA (peds ≥2 years) 

Typical PA requirements 

1. Diagnosis & specialty 

• RA / PsA / AS: 

• Rheumatology diagnosis; PsA may also be co‑managed with dermatology. 

• pJIA / pediatric PsA: 

• Pediatric rheumatology. 

2. Prior therapy / step edits 

• RA: 

• Failure/intolerance of methotrexate (usually mandatory). 

• Often failure of another csDMARD (sulfasalazine, leflunomide). 

• Many plans require trial/failure of a first‑line TNF inhibitor (e.g., Humira/Enbrel) before Simponi Aria. 

• PsA / AS: 

• Inadequate response to NSAIDs ± csDMARDs (MTX, sulfasalazine). 

• Some payers require prior TNF or IL‑17/IL‑23 biologic depending on formulary. 

• pJIA / pediatric PsA: 

• Failure of MTX and often another biologic. 

3. Baseline labs & screening 

• TB test  

• Hepatitis B screening in at‑risk patients 

• CBC/CMP (often requested) 

• HF history, demyelinating disease review 

• Current medication list 

4. Prescriber 

• Rheumatology (adult/peds) ± dermatology for PsA. 

Download Skyrizi order form here.

 Indications payers recognize 

• PsO, PsA, CD, UC in line with PI. 

Typical PA requirements 

1. Psoriasis / Psoriatic arthritis 

• Diagnosis & severity: 

• PsO: moderate–severe disease, inadequate control with topicals ± phototherapy ± systemic (MTX, cyclosporine, acitretin). 

• PsA: active disease with joint involvement and functional impact. 

• Step therapy: 

• Prior failure/intolerance of: 

• For PsO: topical + phototherapy ± systemic; often one biologic (TNF or IL‑17) depending on formulary. 

• For PsA: csDMARD (MTX, sulfasalazine, leflunomide) ± prior biologic (TNF or IL‑17/IL‑23). 

2. Crohn’s disease / Ulcerative colitis 

• Diagnosis & severity: 

• Endoscopic + clinical confirmation of moderate–severe CD or UC (CDAI/SES‑CD, Mayo/partial Mayo). 

• Step therapy: 

• Failure/intolerance of: 

• Steroids and immunomodulators (AZA, 6‑MP, MTX). 

• Often ≥1 biologic/advanced therapy (e.g., anti‑TNF, Entyvio, Stelara, Omvoh, JAK) per plan. 

• Baseline: 

• CBC, CMP (often requested) 

• TB test 

• LFTs + bilirubin (required per PI for CD/UC) 

• Current medication list  

3. Prescriber 

• PsO/PsA: dermatology and/or rheumatology. 

• CD/UC: gastroenterology. 

Download Soliris order form here.

Indications payers recognize 

• PNH, aHUS, gMG (AChR+), NMOSD (AQP4+) 

• All indications require specialist prescriber (hematology, neurology). 

1. PNH 

Documentation: 

• Flow cytometry confirming PIGA mutation / large PNH clone 

• Evidence of hemolysis (LDH elevation) 

• Symptoms: fatigue, abdominal pain, hemoglobinuria, thrombosis 

• Current medication list 

Step therapy: 

• None (Soliris is first‑line for PNH) 

2. aHUS 

Documentation: 

• Clinical diagnosis of TMA 

• Exclusion of Shiga toxin HUS 

• Complement testing sometimes requested 

• Evidence of organ involvement (renal, neurologic, hematologic) 

• Current medication list 

Step therapy: 

• None (Soliris is first‑line for aHUS) 

3. gMG (AChR‑positive) 

Documentation: 

• Confirmed AChR‑antibody positive 

• Moderate–severe generalized MG 

• MG‑ADL and MGFA classification 

• Specialist: neurology 

• Current medication list 

Step therapy (common): 

• Failure/intolerance of: 

• Pyridostigmine 

• Corticosteroids 

• At least one immunosuppressant (AZA, MMF, cyclosporine, tacrolimus) 

• Some plans require failure of IVIG or PLEX 

4. NMOSD (AQP4‑positive) 

Documentation: 

• AQP4‑antibody positive 

• History of relapses 

• MRI supportive findings 

• Specialist: neurology 

• Current medication list 

Step therapy (common): 

• Failure/intolerance of: 

• Rituximab 

• Immunosuppressants (AZA, MMF) 

• Some plans require failure of Uplizna or Enspryng depending on formulary 

Mandatory Safety Requirements 

1. Meningococcal vaccination (REMS requirement) 

This is the single most important PI requirement. 

• Must receive MenACWY + MenB ≥2 weeks before first dose 

• If urgent treatment is required: 

• Start antibiotic prophylaxis until 2 weeks post‑vaccination 

• Enrollment in Soliris REMS is required 

• Patients must be counseled on meningococcal infection symptoms 

Download SQIG order form here.

Chart Notes Supporting Diagnosis 

• ☐ Detailed history & physical exam 

• ☐ Documentation of recurrent or severe infections (if applicable) 

• ☐ 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 Stelara & Biosimilars order forms here:

Indications payers recognize 

• PsO, PsA, CD, UC in line with PI, with age cutoffs. 

1. Psoriasis / Psoriatic arthritis 

• Diagnosis & severity: 

• PsO: moderate–severe disease; inadequate control with topicals ± phototherapy ± systemic (MTX, cyclosporine, acitretin). 

• PsA: active joint disease with functional impact. 

• Step therapy: 

• Prior failure/intolerance of: 

• PsO: topical + phototherapy ± systemic; often one biologic (TNF or IL‑17) depending on formulary. 

• PsA: csDMARD (MTX, sulfasalazine, leflunomide) ± prior biologic (TNF or IL‑17/IL‑23). 

• Baseline labs: 

• TB test 

• Prescriber: 

• Dermatology (PsO) and/or rheumatology (PsA). 

2. Crohn’s disease / Ulcerative colitis 

• Diagnosis & severity: 

• Endoscopic + clinical confirmation of moderate–severe CD or UC (CDAI/SES‑CD, Mayo/partial Mayo). 

• Step therapy: 

• Failure/intolerance of: 

• Steroids and immunomodulators (AZA, 6‑MP, MTX). 

• Often ≥1 biologic/advanced therapy (anti‑TNF, Entyvio, Skyrizi/Omvoh, JAK) per plan. 

• Baseline labs: 

• TB test 

• Prescriber: 

• Gastroenterology. 

Chart Notes Supporting Diagnosis 

• Moderate–severe plaque psoriasis (PsO) – adult & peds ≥6 

• Active psoriatic arthritis (PsA) – adult & peds ≥6 

• Moderately–severely active Crohn’s disease (CD) – adult & peds ≥2  

• Moderately–severely active ulcerative colitis (UC) 

Required Labs 

• ☐ TB screening 

Typical PA requirements 

• Diagnosis & severity: 

• PsO: moderate–severe, candidate for systemic/phototherapy 

• PsA: active disease 

• CD/UC: moderate–severe, objective documentation (scope, imaging, labs) 

• Current medication list 

Step therapy 

• PsO/PsA: failure/intolerance of csDMARDs (MTX, leflunomide, sulfasalazine) and/or phototherapy; many plans require failure of ≥1 TNF inhibitor (Humira, Enbrel, Remicade). 

• CD/UC: failure/intolerance of steroids, immunomodulators (AZA, 6‑MP, MTX), and often one biologic (e.g., anti‑TNF or Entyvio) 

Download Tepezza order form here.

Indication payers recognize 

• Thyroid eye disease (TED) in adults 

• Usually require moderate–to–severe, active TED with functional impact. 

Typical PA requirements 

• Diagnosis & severity: 

• Documented TED with: 

• Proptosis and/or 

• Diplopia and/or 

• Pain/inflammation, lid retraction, exposure keratopathy 

• Often want clinical activity score (CAS) or narrative showing active disease. (CAS >4) (helpful, not required) 

• Current medication list 

• Prior/alternative therapy: 

• Documentation of: 

• Trial or consideration of steroids, orbital radiation, or surgery 

• Or clear rationale why Tepezza is preferred (rapid progression, poor steroid response, high surgical risk). 

• Baseline screening / comorbidities: 

• Diabetes or prediabetes status (because of hyperglycemia risk) 

• IBD history (Crohn’s/UC) due to risk of exacerbation  

Download Tezspire order form here.

Indication payers recognize 

• Add‑on maintenance treatment of severe asthma in patients ≥12 years 

• Usually framed as “severe, uncontrolled asthma despite high‑intensity therapy.” 

Typical PA requirements 

• Diagnosis & severity: 

• Documented severe asthma with: 

• Frequent exacerbations (e.g., ≥2 steroid bursts or ≥1 hospitalization/ED visit in past 12 months) 

• Persistent symptoms despite high‑dose ICS + LABA 

• Baseline therapy: 

• On high‑dose ICS + LABA 

• Often plus another controller (LAMA, LTRA, or chronic oral steroids) 

• Phenotype/biomarkers (payer‑driven, not PI): 

• Many plans ask for: 

• Blood eosinophils, IgE, or FeNO 

• History of allergic or eosinophilic asthma—even though Tezspire is phenotype‑agnostic by label 

• Exclusions/attestations: 

• Not used for COPD, acute bronchospasm, or status asthmaticus 

• No concurrent biologic for asthma (Xolair, Nucala, Fasenra, Dupixent) 

• Prescriber: pulmonologist or allergy/immunology specialist. 

• Current medication list 

Required Labs & Testing 

• ☐ Spirometry (FEV1, FEV1/FVC) 

• ☐ Eosinophil count 

• ☐ IgE level 

• ☐ FeNO (if available) 

• ☐ Chest imaging (if done) 

Exacerbation Documentation 

• ☐ ≥2 steroid‑requiring exacerbations in past 12 months 

• ☐ OR ≥1 hospitalization/ED visit 

• ☐ Dates of exacerbations 

• ☐ Steroid bursts 

• ☐ Hospital/ED visits 

Download Tremfya order form here. 

Indications payers recognize  

• Moderate–severe plaque psoriasis (PsO) – adults and peds ≥6 years, ≥40 kg 

• Active psoriatic arthritis (PsA) – adults and peds ≥6 years, ≥40 kg 

• Moderately–severely active ulcerative colitis (UC) – adults 

• Moderately–severely active Crohn’s disease (CD) – adults  

Typical PA requirements 

• Diagnosis & severity: 

• PsO: moderate–severe, candidate for systemic therapy or phototherapy  

• PsA: active disease 

• UC/CD: moderate–severe with objective documentation (scope, imaging, labs) 

• Step therapy (payer‑driven): 

• PsO/PsA: failure/intolerance of csDMARDs (MTX, leflunomide, sulfasalazine) and/or phototherapy; many plans require failure of ≥1 TNF inhibitor (Humira, Enbrel, Remicade). 

• UC/CD: failure/intolerance of steroids, immunomodulators (AZA, 6‑MP, MTX), and often one biologic (anti‑TNF, Stelara, Entyvio). 

• Baseline screening: 

• TB test  

• Prescriber: dermatology, rheumatology, or GI depending on indication. 

• Current medication list 

Download Tysabri order form here.

Diagnosis Requirements 

• Relapsing forms of MS (CIS, RRMS, active SPMS)  

• Moderately–severely active Crohn’s disease with inflammation and failure of conventional therapy + TNF inhibitors  

 TOUCH® Program Requirements 

• Provider, facility, and patient must be enrolled in TOUCH® 

• Documentation of baseline JCV status, MRI, and ongoing monitoring 

• Payers often require TOUCH forms attached 

Safety Documentation 

• JCV antibody status (positive/negative + index, date of test) 

• Baseline MRI prior to initiation (payer requirement; PI requires monitoring for PML) 

• No concurrent immunosuppressants or TNF inhibitors for Crohn’s (PI limitation)  

• No active infection 

Chart Notes 

• MS: relapse history, MRI findings, prior DMT failures 

• Crohn’s: endoscopy/imaging, steroid/biologic history, inflammation documentation 

• Current medication list 

 Prescriber 

• Neurology (MS) 

• Gastroenterology (Crohn’s) 

Required Documentation 

MS: 

• ☐ MRI brain ± spine 

• ☐ JCV antibody 

Crohn’s: 

• ☐ Endoscopy 

Treatment History 

• ☐ Prior DMTs (MS) 

• ☐ Steroids (MS) 

• ☐ Steroids, immunomodulators, biologics, JAK inhibitors (Crohn’s) 

• ☐ Dose, dates, response, reason stopped 

Download Uplizna order form here.

Indications payers recognize 

• NMOSD – adult, AQP4‑antibody positive 

• IgG4‑related disease (IgG4‑RD) – adult 

• Generalized myasthenia gravis (gMG) – adult, AChR‑ or MuSK‑antibody positive  

Typical PA requirements 

• Correct, antibody‑confirmed diagnosis: 

• NMOSD: documented AQP4‑Ab positivity, relapse history, MRI/spinal cord involvement 

• IgG4‑RD: organ involvement, biopsy or serologic evidence 

• gMG: AChR or MuSK Ab positivity, MGFA class, functional impact  

• Prior therapy / refractoriness (payer‑driven): 

• NMOSD: failure/intolerance of conventional immunosuppressants (e.g., azathioprine, MMF, rituximab) 

• gMG: failure/intolerance of standard MG therapies (pyridostigmine, steroids, immunosuppressants ± IVIG/PLEX) 

• IgG4‑RD: inadequate response to steroids ± steroid‑sparing agents 

• Baseline labs / screening (usually required by plans): 

• HBV panel, TB test, quantitative immunoglobulins (mirrors PI)  

• CBC/CMP as general safety labs 

• Exclusions/attestations: 

• No active hepatitis B 

• No active or untreated latent TB 

• No active serious infection at time of infusion  

• Prescriber: neurology (NMOSD/gMG) or appropriate subspecialist (IgG4‑RD). 

• Current medication list 

Required assessments before first dose 

• Hepatitis B virus testing 

• Quantitative serum immunoglobulins 

• Tuberculosis screening  

Before every infusion 

• Determine if there is an active infection 

• Premedicate with: 

• Corticosteroid 

• Antihistamine 

• Antipyretic 

Download Ultomiris order form here.

Chart Notes Supporting Diagnosis 

• ☐  gMG – AChR‑antibody–positive, ≥6 years 

• ☐ NMOSD – AQP4‑antibody–positive adults 

• ☐ gMG/NMOSD: failure/intolerance of standard immunosuppressants ± IVIG/plasma exchange (payer‑driven) 

• ☐ Symptom history 

• ☐ Functional impact 

• ☐ Current medication list 

• ☐ Enrollment in ULTOMIRIS/SOLIRIS REMS program 

REQUIRED Vaccination Documentation 

Ultomiris increases meningococcal infection risk. Payers require: 

• ☐ Meningococcal ACWY vaccination 

• ☐ Meningococcal B vaccination 

• ☐ If vaccinations not completed → documentation of prophylactic antibiotics 

• ☐ Vaccination dates 

Required Labs & Diagnostic Testing (Indication‑Specific) 

• gMG: 

• ☐ AChR antibody 

• ☐ MG‑ADL and MGFA score 

• NMOSD: 

• ☐ AQP4 antibody 

• ☐ MRI 

• ☐ Relapse history 

• ☐ All prior therapies documented 

• ☐ Dose, dates, response, reason stopped 

Download Vyepti order form here.

Indication payers recognize 

• Preventive treatment of migraine in adults (often specifically chronic or high‑frequency episodic migraine) 

Typical PA requirements 

• Diagnosis & severity: 

• Documented migraine with: 

• Current medication list 

• ≥4–8 migraine days/month (plan‑specific) 

• Often chronic migraine (≥15 headache days/month, ≥8 migraine days) 

• Symptom history (photophobia, phonophobia, nausea, aura)  

• Prescriber: 

• Neurologist or headache specialist (common requirement) 

• Baseline considerations (payer‑driven): 

• Blood pressure history (due to hypertension warning) 

• Constipation history and GI risk 

• History of Raynaud’s or peripheral vascular disease 

Treatment History (CRITICAL for approval) 

Oral Preventives 

• ☐ Beta‑blockers (propranolol, metoprolol) 

• ☐ Anticonvulsants (topiramate, valproate) 

• ☐ Antidepressants (amitriptyline, venlafaxine) 

Other Preventives 

• ☐ Botox (if chronic migraine) 

• ☐ Other CGRP mAbs (Aimovig, Ajovy, Emgality) 

• ☐ 60‑day trial/failure OR documented reason unable to complete 

• ☐ Gepants (Qulipta, Nurtec ODT for prevention) 

For each therapy: 

• ☐ Dose 

• ☐ Dates 

• ☐ Response 

• ☐ Reason discontinued 

Download Vyvgart order form here.

Chart Notes Supporting Diagnosis 

• ☐ Neurology notes confirming gMG or CIDP 

• ☐ Symptom history (ptosis, diplopia, bulbar symptoms, limb weakness, gait issues) 

• ☐ Neurologic exam findings 

• ☐ Current medication list 

• ☐ Documentation of exacerbations, hospitalizations, or steroid dependence 

Required Diagnostic Testing 

For gMG 

Payers accept ANY of the following: 

• ☐ AChR‑Ab positive 

• ☐ MuSK‑Ab positive 

• ☐ LRP4‑Ab positive 

• ☐ Triple seronegative (requires strong documentation) 

Also include: 

• ☐ MG‑ADL score and MGFA classification 

• ☐ EMG/NCS (if performed) 

For CIDP 

• ☐ EMG/NCS confirming demyelinating neuropathy 

• ☐ CSF protein elevation (if available) 

• ☐ MRI spine (if performed) 

Treatment History 

For gMG 

• ☐ Pyridostigmine 

• ☐ Steroids 

• ☐ IVIG 

• ☐ PLEX 

• ☐ Immunosuppressants (AZA, MMF, cyclosporine, tacrolimus) 

• ☐ Other biologics (Soliris, Ultomiris, Rituximab) 

For CIDP 

• ☐ IVIG 

• ☐ Steroids 

• ☐ PLEX 

• ☐ Immunosuppressants 

For each therapy: 

• ☐ Dose 

• ☐ Dates 

• ☐ Response 

• ☐ Reason discontinued 

Payer expectation: 

• ☐ Failure or intolerance of ≥1 prior therapy OR documented moderate–severe disease 

Download Vyvgart Hytrulo form here.

Chart Notes Supporting Diagnosis 

• ☐ Neurology notes confirming gMG or CIDP 

• ☐ Symptom history (ptosis, diplopia, bulbar symptoms, limb weakness, gait issues) 

• ☐ Neurologic exam findings 

• ☐ Current medication list 

• ☐ Documentation of exacerbations, hospitalizations, or steroid dependence 

Required Diagnostic Testing 

For gMG 

Payers accept ANY of the following: 

• ☐ AChR‑Ab positive 

• ☐ MuSK‑Ab positive 

• ☐ LRP4‑Ab positive 

• ☐ Triple seronegative (requires strong documentation) 

Also include: 

• ☐ MG‑ADL score and MGFA classification 

• ☐ EMG/NCS (if performed) 

For CIDP 

• ☐ EMG/NCS confirming demyelinating neuropathy 

• ☐ CSF protein elevation (if available) 

• ☐ MRI spine (if performed) 

Treatment History 

For gMG 

• ☐ Pyridostigmine 

• ☐ Steroids 

• ☐ IVIG 

• ☐ PLEX 

• ☐ Immunosuppressants (AZA, MMF, cyclosporine, tacrolimus) 

• ☐ Other biologics (Soliris, Ultomiris, Rituximab) 

For CIDP 

• ☐ IVIG 

• ☐ Steroids 

• ☐ PLEX 

• ☐ Immunosuppressants 

For each therapy: 

• ☐ Dose 

• ☐ Dates 

• ☐ Response 

• ☐ Reason discontinued 

Payer expectation: 

• ☐ Failure or intolerance of ≥1 prior therapy OR documented moderate–severe disease 

Download Xolair order form here.

Approved Indications (Payer‑recognized) 

• Moderate–severe allergic asthma (≥6 years) with: 

• Positive perennial aeroallergen testing 

• Symptoms inadequately controlled on ICS 

• Chronic rhinosinusitis with nasal polyps (CRSwNP) (≥18 years) 

• Chronic spontaneous urticaria (CSU) (≥12 years) 

• IgE‑mediated food allergy (≥1 year) for reduction of reactions with accidental exposure 

• Must be used with food allergen avoidance 

 Step Therapy (common payer requirements) 

• Asthma: 

• Failure of high‑dose ICS + LABA 

• Positive skin test or specific IgE to perennial allergen 

• CSU: 

• Failure of high‑dose H1 antihistamines 

• Hives >6 weeks 

• CRSwNP: 

• Failure of intranasal corticosteroids 

• Food allergy: 

• Documentation of confirmed IgE‑mediated food allergy 

• History of reactions and avoidance counseling 

Required Baseline Documentation 

• Total serum IgE (IU/mL) 

• Body weight (kg) 

• Required for dose determination (PI‑mandated)  

• Allergen testing (asthma, food allergy) 

• H1 antihistamine failure (CSU) 

• Nasal endoscopy/CT (CRSwNP) 

• Current medication list