Autoimmune and Biosimilars Referral Form

To submit this form, complete all required fields and gather necessary documentation. Send the completed form via email to DL-NCCNEWREFERRAL@cvshealth.com or fax to 1-866-843-3221. Alternatively, you can submit the form online at cvs.co/remicade-enrollment for expedited processing. Ensure all information is accurate to avoid delays. For assistance, contact the concierge service team at 1-866-899-1661. Make sure to adhere to submission deadlines for timely processing.

Ensure to submit the referral form by the end of each quarter for timely processing. For 2024 and 2025, consider submitting by March 31st, June 30th, September 30th, and December 31st to align with the quarterly processing schedule.

The purpose of this form is to facilitate the referral process for patients requiring autoimmune therapies and biosimilar medications. By providing a comprehensive and organized format, healthcare providers can ensure all necessary patient information and documentation are included. This form streamlines communication between providers, patients, and insurance companies, leading to improved patient care and more efficient processing of referrals.

• 1. Patient demographics and insurance information: Includes fields for patient name, date of birth, contact details, and insurance coverage.
• 2. Prescription details: Fields for the prescribed drug name, dosage, and frequency of administration.
• 3. Clinical documentation: Supporting documents such as history and physical (H&P), previous treatments, and tuberculosis (TB) test results.
• 4. Available therapies: List of available therapies including Avsola, Inflectra, Infiximab, Remicade, and Renflexis.
• 5. Common ICD-10 codes: Relevant ICD-10 codes for autoimmune therapy diagnoses such as Crohn's disease and rheumatoid arthritis.
• 6. Concierge service team contact information: Details for contacting the centralized referral intake team including phone numbers, fax, and email addresses.

Failure to submit this form can result in delays or denial of therapy for the patient. It may also hinder the approval process with insurance companies.

• Delayed treatment: Patients may face delays in receiving necessary therapies.
• Insurance approval issues: Lack of proper documentation may result in insurance denials.
• Incomplete patient records: Failure to submit can result in gaps in patient medical records.

• 1. Patient referral for therapy: When a patient needs to start or continue autoimmune therapy.
• 2. Insurance verification: To provide necessary documentation for insurance approvals.
• 3. Updated patient records: To maintain comprehensive and up-to-date patient medical records.