Palmetto Infusion Plans of Treatment
To refer a patient, please choose the appropriate plan of treatment from the list below and fax to 1‐866‐872‐8920, or call 1‐800‐809‐1265 for assistance. Providers can also submit a plan of treatment electronically using the “Upload POTs/Referral Docs” button below.
In addition to a signed and dated Plan of Treatment, please provide the following information to expedite the referral process:
- Diagnosis / ICD-10 diagnosis code
- Most recent history and physical including:
- Current / complete medication list
- Most recent office visit notes
- Past medical history
- Tried and failed therapies
- Allergy history
- Current height / weight
- Drugs and dosing schedule, including last dose and next dose due if applicable
- Most recent lab/test results clinically relevant to therapy. For example: Hep B panel, Calcium and CrCl, PPD Test, etc.
- Insurance information
- Actemra Plan of Treatment Adult Rheumatology
- Actemra Plan of Treatment Pediatric Rheumatology
- Adakveo Plan of Treatment
- Albumin Standard Plan of Treatment
- Aldurazyme Plan of Treatment
- Alpha 1-Antitrypsin Deficiency Standard Plan of Treatment
- Amvuttra Plan of Treatment
- Antibiotics (Anti-infective) Standard Plan of Treatment (AIC)
- Anti-Infective (Antibiotics, Antivirals, and Antifungals) Plan of Treatment (Home Infusion)
- Avsola Dermatology Plan of Treatment
- Avsola Gastroenterology Plan of Treatment
- Avsola Rheumatology Plan of Treatment
- Benlysta Standard Plan of Treatment
- Boniva (ibandronate sodium) Standard Plan of Treatment
- Briumvi Plan of Treatment
- Cabenuva Plan of Treatment
- Cerezyme POT ICD 10 102215
- Cimzia Plan of Treatment for Gastroenterology
- Cimzia Plan of Treatment for Rheumatology
- Cinqair Plan of Treatment
- Cosentyx Plan of Treatment
- Crysvita Plan of Treatment for Adult Patients
- Crysvita Plan of Treatment for Pediatric Patients
- Dalvance Plan of Treatment
- Elaprase POT ICD 10 102215
- Entyvio Plan of Treatment
- Evenity Standard Plan of Treatment
- Evkeeza Standard Plan of Treatment
- Fabrazyme Standard Plan of Treatment
- Fasenra Standard Plan of Treatment
- Fasenra Standard Plan of Treatment for Pediatric Patients
- Generic or Blank Plan of Treatment
- Givlaari Plan of Treatment
- Home Infusion Standing Order
- Hydration Standard Plan of Treatment
- HyQvia Standard Plan of Treatment
- Ilumya Plan of Treatment
- Immunoglobulin (IVIG) Plan of Treatment
- Immunoglobulin (IVIG) Plan of Treatment (Home Infusion)
- Immunoglobulin Subcutaneous Standard Plan of Treatment
- Inflectra Dermatology Plan of Treatment
- Infliximab Dermatology Plan of Treatment (Home Infusion)
- Inflectra Gastroenterology Plan of Treatment
- Infliximab Gastroenterology Plan of Treatment (Home Infusion)
- Inflectra Rheumatology Plan of Treatment
- Infliximab Rheumatology Plan of Treatment (Home Infusion)
- Intralipids Plan of Treatment
- Iron Standard Plan of Treatment
- Keytruda Plan of Treatment
- Kimyrsa Standard Plan of Treatment
- Krystexxa Standard Plan of Treatment
- Lemtrada Plan of Treatment (Not available in all locations)
- Leqvio Plan of Treatment
- Levothyroxine Standard Plan of Treatment
- Line Care Alteplase (Cathflo Activase) Standard Plan of Treatment (AIC)
- Cathflo Plan of Treatment (Home Infusion)
- Line Care Standard Plan of Treatment (AIC)
- Line Care Plan of Treatment (Home Infusion)
- Lumizyme Plan of Treatment ICD 10 102215
- Magnesium Standard Plan of Treatment
- Nexviazyme Standard Plan of Treatment
- Nucala Plan of Treatment for Asthma
- Nucala Plan of Treatment for EGPA
- Nucala Standard Plan of Treatment for Nasal Polyps
- Nucala Hypereosinophilic Syndrome (HES) Plan of Treatment
- Nucala Plan of Treatment for Pediatric Asthma
- Nulojix Standard Plan of Treatment
- Ocrevus Plan of Treatment
- Omvoh Plan of Treatment
- Onpattro Plan of Treatment
- Opdivo Plan of Treatment
- Orbactiv Standard Plan of Treatment
- Orencia Adult Rheumatology Plan of Treatment
- Orencia Pediatric Rheumatology Plan of Treatment
- Prolia Standard Plan of Treatment
- Radicava Plan of Treatment
- Reclast (zoledronic acid) Standard Plan of Treatment
- Remicade Dermatology Plan of Treatment
- Remicade Gastroenterology Plan of Treatment
- Remicade Rheumatology Plan of Treatment
- Renflexis Dermatology Plan of Treatment
- Renflexis Gastroenterology Plan of Treatment
- Renflexis Rheumatology Plan of Treatment
- Riabni Plan of Treatment for GPA-MPA
- Riabni Plan of Treatment for Rheumatology
- Rituxan Plan of Treatment for GPA-MPA
- Rituxan Plan of Treatment for Rheumatology
- Ruxience Plan of Treatment for GPA-MPA
- Ruxience Plan of Treatment for Rheumatology
- Rystiggo Plan of Treatment
- Saphnelo Standard Plan of Treatment
- Simponi ARIA Standard Plan of Treatment
- Simponi ARIA Standard Plan of Treatment for Pediatric Patients
- Skyrizi Plan of Treatment for Crohn’s
- Skyrizi Plan of Treatment for UC
- Soliris Plan of Treatment for aHUS
- Soliris Plan of Treatment for aHUS for Pediatric Patients
- Soliris Plan of Treatment for Myasthenia Gravis
- Soliris Plan of Treatment for NMOSD
- Soliris Plan of Treatment for PNH
- Solumedrol (Methylprednisolone) Plan of Treatment (AIC)
- Solumedrol Plan of Treatment (Home Infusion)
- Spevigo Plan of Treatment
- Standing Adverse Reaction Orders
- Stelara Plan of Treatment for Rheumatology and Dermatology
- Stelara Plan of Treatment for Gastroenterology
- Tepezza Plan of Treatment
- Tezspire Plan of Treatment
- Trogarzo Plan of Treatment
- Truxima Plan of Treatment for GPA-MPA
- Truxima Plan of Treatment for Rheumatology
- Tysabri Standard Plan of Treatment
- Tzield Plan of Treatment
- Ultomiris Plan of Treatment
- Uplizna Plan of Treatment
- Vimizim Plan of Treatment
- Vpriv Plan of Treatment
- Vyepti Plan of Treatment
- Vyvgart Plan of Treatment
- Vyvgart Hytrulo Plan of Treatment
- Vyvgart Hytrulo Plan of Treatment for CIDP
- Xolair Standard Plan of Treatment for Asthma
- Xolair IgE- Standard Plan of Treatment for Medicated Food Allergies
- Xolair Standard Plan of Treatment for Nasal Polyps
- Xolair Standard Plan of Treatment for Urticaria
- Xgeva Plan of Treatment
- Zemdri Plan of Treatment