ILARIS^® Service Request Form (SRF)

Initiate the ILARIS^® Prescription Process

ILARIS® (canakinumab) is only available through a specialty pharmacy provider network. Prescribing and obtaining ILARIS® for your patients is easy.

• Step 1. Simply download the ILARIS® Service Request Form
• Step 2. Complete the form and review it with your patient
• Step 3. Fax the signed form back to 1-866-972-8316 to enroll patients in the ILARIS® Patient Support Program

Once you have submitted the ILARIS® SRF, the ILARIS® Patient Support Program will then work with you to continue the process of filling the prescription:

• Step 4. The ILARIS® Patient Support Program will contact the patient's insurance company
• Step 5. The ILARIS® Patient Support Program will then contact you and your patient to confirm the patient's benefits and to request any authorizations or other information needed
• Step 6. If the ILARIS® Patient Support Program is able to secure coverage for your patient, they will work with you and a specialty pharmacy provider network to set up shipment of the prescription