Soliris® (eculizumab)

Fabricante
Alexion Pharmaceuticals, Inc.

Please print and complete one of the following forms below, based on diagnosis. Una vez completados, envíelos al número de fax que figura en el formulario. Either the Accredo enrollment form or the manufacturer enrollment form is acceptable.

Please note that if you use a manufacturer enrollment form, you will need to indicate your pharmacy of choice on your coversheet in order for it to route to the appropriate pharmacy.

Referral forms available for Soliris® (eculizumab):

Myasthenia Gravis

Paroxysmal Nocturnal Hemoglobinuria (PNH)/Atypical Hemolytic Uremic Syndrome (aHUS)

Neuromyelitis Optica Spectrum Disorder (NMOSD)