Stelara SQ

Referral Guide

The following guide lists the information we need to ensure a quick, seamless patient referral for a Stelara SQ 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
• Patient's current weight and height
• For Crohn's patients, include date of induction dose given
• Clinicals to support one or more of the following:
  • Patient has moderately to severely active Crohn’s disease (CD) and evidence to support one or more of the following:
    • Failed or was intolerant to treatment with immunomodulators or corticosteroids but never failed treatment with a tumor necrosis factor blocker OR
    • Failed or was intolerant to treatment with one or more TNF blockers
• Patient has active psoriatic arthritis
• Patient has moderate to severe plaque psoriasis who is a candidate for phototherapy or systemic therapy

Ready to make a referral?
Download our referral form.