SOLIRIS® (Eculizumab)
Order Form

SOLIRIS® (eculizumab)

SOLIRIS® is used to treat adults with neuromyelitis optica spectrum disorder (NMOSD) who are anti-aquaporin-4 (AQP4) antibody-positive, as well as have paroxysmal nocturnal hemoglobinuria (PNH), hemolytic uremic syndrome (aHUS), and myasthenia gravis. The recommended dosage may vary depending on the condition being treated.

Please refer to the full prescribing information.

Note: Please speak with your healthcare provider for more information if you think this therapy might be right for you.

How do I make a referral or transition my treatment to Infusion Associates?

1. Ask your healthcare provider to fax us a completed order form for your medication, clinical notes, demographics and your insurance card to (833) 996-4888.

2. Providers can find order forms on our medications page.

3. One of our intake specialists will contact your healthcare provider to confirm receipt of your referral.

4. We will then verify benefits, obtain any required prior authorizations, and contact you to schedule an appointment.