Actemra

Referral Guide

The following guide lists the information we need to ensure a quick, seamless patient referral for an Actemra injection treatment.

All referrals must include:

• Order
• Patient Demographics
• Supporting Clinicals (Notes and Labs)

Order Information:

• Provider name
• NPI#
• Address
• Phone/Fax
• Provider signature (or electronically authenticated signature)

Patient Demographics:

• Patient name
• Phone number
• Address
• Insurance information (primary and secondary if applicable)

Supporting Clinicals (Notes and Labs):

• Results of a recent tuberculosis (TB) skin/lab testing
• Clinicals to support one or more of the following:
  • Patient has moderately to severely active rheumatoid arthritis (RA) who has had an inadequate response to one or more disease modifying anti-rheumatic drugs (DMARDs)
  • Patient has giant cell arteritis (GCA)
  • Patient has active polyarticular juvenile idiopathic arthritis
  • Patient has active systemic juvenile idiopathic arthritis

Ready to make a referral?
Download our Actemra Order Form.