Omvoh (Mirikizumab-mrkz)
LILLY
- Ulcerative Colitis
- 300 mg IV at Weeks 0, 4, and 8
- Need patient weight, QuantiFERON, CMP
Instructions
1 – Please open authorization forms (above). Fill out the forms on your computer, save and print.
2 – Open Physician Orders for the office of your choice (above). Save to your computer, print and fill out.
3 – The following tests should be performed and test results faxed to Pacific Infusion before the patient’s first visit: Omvoh (Mirikizumab-mrkz) – PPD or QuantiFERON test, CMP
4 – Fax the following to Pacific Infusion Center (310) 297-9222:
ㅤ• Completed and signed forms/order
ㅤ• Copy of the patient’s insurance card(s)
ㅤ• Demographics
ㅤ• OV notes
ㅤ• Tried and failed medications
ㅤ• Labs
ㅤ• Drug Enrollment Forms
5 – After the patient’s infusion appointment, our nurses will fax a copy of the infusion notes to your office.
