Soliris® (eculizumab)

Please print and complete one of the following forms below, based on diagnosis. Once completed, fax to the number indicated on the form. 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

• Soliris® (eculizumab) Accredo Referral Form
• Soliris® (eculizumab) Manufacturer Referral Form

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

• Soliris® (eculizumab) Accredo Referral Form
• Soliris® (eculizumab) Manufacturer Referral Form

Neuromyelitis Optica Spectrum Disorder (NMOSD)

• Soliris® (eculizumab) Accredo Referral Form
• Soliris® (eculizumab) Manufacturer Referral Form