Pulmonary Arterial Hypertension (PAH) Enrollment Form FaxReferral Referral Fax To:To: 877-943-1000 Phon Phone: 877-242-2738 Email Referral To: To: [email protected] E-mail Referral 6 Simple steps to submitting a referral 1 PATIENT INFORMATION 22 PRESCRIBER INFORMATION Prescriber’s Name: (Complete the following or include demographic sheet) Patient Name: State License #: Address: DEA #: City, State, Zip: NPI #: Group or Hospital: Primary Phone: Home Alternate Phone: Home DOB: Gender: Cell Cell Work Address: Work City, State Zip: Male Female E-mail: Last Four of SS #: Phone: Fax: Contact Person: Phone: Primary Language: INSURANCE INFORMATION Please fax copy of prescription and insurance cards with this form, if available (front and back) 3 4 DIAGNOSIS AND CLINICAL INFORMATION Needs by Date: Ship to: Patient Office Other: Diagnosis (ICD-9 or ICD-10) 416.0 Idiopathic/ familial Pulmonary Arterial Hypertension 416.8 Secondary Pulmonary Arterial Hypertension ICD-10 Code & Description: Secondary to: Date of Diagnosis: Duration of Therapy: Clinical Information New York Heart Association (NYHA) Functional Classification: I 6 minute Walk Distance II III IV meters Is patient currently on another therapy for pulmonary hypertension? Yes No If Yes, name of drug(s): Allergies: Height: Attach copies of: History and Physical Right Heart Catheterization Calcium Channel Blocker statement Weight: Echocardiogram Nursing Needs: Start of care date: Not needed Number of visits: Pre-hospital/ Pre-home Teaching In-Hospital Teaching Nursing Follow-up Prostacyclin Referral Information: Check the boxes below to designate which items are included in this fax: PAH Diagnosis and ICD-9 code (designated on PAH Referral Form) Is Medicare Part B the primary insurance for this referral? Yes No Clinical documentation: Current H&P (within 6 months) Date of H&P: Right Heart Catheterization (RHC); Check below if included in the RHC Report: Mean PA Pressure (or systolic/diastolic) > 25 mmHg at rest or 30 mmHg with exertion Cardiac Output Cardiac Index Pulmonary Vascular Resistance Pulmonary Capillary Wedge Pressure (or LVEDP) < 15 mmHg Echocardiogram Calcium channel blocker statement with supporting documentation Patients with the following secondary disease states will require documentation that the PAH is out-of-proportion with the secondary disease. • Left heart disease, valvular heart disease, lung disease, Sarcoidosis and other co-morbidities, except for the ones listed in WHO Group I category Page 1 of 2 IMPORTANT intended to to bebe delivered only to the named addressee andand maymay contain material that that is confidential, privileged, proprietary or exampt from disclosure under under applicable law. If law. it is received by anyone other than the named IMPORTANTNOTICE: NOTICE:This Thisfacsimile facsimiletransmission transmissionis is intended delivered only to the named addressee contain material is confidential, privileged, proprietary or exempt from disclosure applicable If it is received by anyone addressee, the named recipientaddressee, should immediately notify the sender at the address and telephone setand forth herein and obtainset instructions as to disposal the transmitted In the no even should such material read should or retained anyonebe other other than the the recipient should immediately notify the sender at thenumber address telephone number forth herein and obtain of instructions as to material. disposal of transmitted material. In nobe event suchby material readthan or the named addressee, except by express authority of the sender to the named addressee. Pulmonary Arterial Hypertension 031014 retained by anyone other than the named addressee, except by express authority of the sender to the named addressee. Pulmonary Arterial Hypertension 031014 Pulmonary Arterial Hypertension (PAH) Enrollment Form Pulmonary Arterial Hypertension (PAH) Enrollment Form FaxReferral ReferralTo: To:877-943-1000 Fax EmailReferral ReferralTo: To:[email protected] Email Phone:877-242-2738 Phone: PATIENT INFORMATION Patient Name: 5 DOB: Prescriber’s Name: PRESCRIPTION INFORMATION MEDICATION Adcirca (tadalafil) DIRECTIONS Oral/Inhaled HEPATITIS Therapy C DOSE/STRENGTH QUANTITY Take 40mg (2 tablets) once a day Other: 20 mg tablet Adempas (riociguat) Please complete a copy of Adempas Patient Enrollment and Consent form by accessing www.adempasREMS.com or calling 855-423-3672 and indicate CVS Caremark as your preferred pharmacy provider. Letairis (ambrisentan) Please complete a copy of the LEAP enrollment/consent form by accessing www.letairisrems.com or calling 1-866-664-LEAP (5327) and indicate CVS Caremark as your preferred pharmacy provider. Opsumit (macitanten) Please complete a copy of the Patient Enrollment and Consent form by accessing www.opsumitrems.com or calling 1-866-228-3546 and indicate CVS Caremark as your preferred pharmacy provider. Orenitram (tresprostinil) extended release tablets Please complete a copy of the Orenitram Therapy Referral Form by calling 1-877-864-8437 and indicate CVS Caremark as your preferred pharmacy provider. Revatio (sildenafil) 20 mg tablet Take one tablet three times a day Other: Generic sildenafil 20 mg tablet Take one tablet three times a day Other: Tracleer (bosentan) REFILLS Please complete a copy of the TAP enrollment/consent form by accessing http://www.tracleerrems.com or calling (866)228-3546 and indicate CVS Caremark as your preferred pharmacy provider. Tyvaso (tresprostinil) Inhalation Solution Tyvaso Inhalation System Starter Kit (28 day supply) Start with 3 breaths (18mcg) four times daily. Increase by 3 breaths at 1-2 week intervals, if tolerated, until the target dose of 9 breaths (54mcg) four times daily Other: Tyvaso Inhalation Solution Refill Kit (28 day supply) Ventavis (iloprost) Inhalation Solution Please complete a copy of the Ventavis enrollment form by accessing http://www.4ventavis.com/pdf/Ventavis_Patient_Enrollement_Forms.pdf or calling (866)228-3546 and indicate CVS Caremark as your preferred pharmacy provider. Infused Therapy ® Remodulin (treprostinil) for injection ® Veletri (epoprostenol) for injection Epoprostenol 1mg/ml 20ml vial 2.5mg/ml 20ml vial 5mg/ml 20ml vial 10mg/ml 20ml vial 0.5mg vial 1.5mg vial 0.5mg vial 1.5mg vial Epoprostenol diluent Subcutaneous infusion continuous over 24 hours Initiation dosage ng/kg/min. Titrate by ng/kg/min every days until goal of ng/kg/min is achieved. Change infusion site every days. Palliative med PRN Pumps: 2 CADD-MS 3 pumps IV Infusion continuous over 24 hours Initiation dosage ng/kg/min. Titrate by ng/kg/min every days until goal of ng/kg/min is achieved. CVC Care: Dressing change every days Per IV standard of care Pump: 2 CADD-Legacy Pumps 2 CADD-MS 3 Pumps 2 Crono Five Pumps Check one (0.9% Sodium Chloride will be used in no box is checked): 0.9% Sodium Chloride for injection Sterile Water for injection Epoprostenol Sterile diluent for injection IV infusion continuous over 24 hours Initial dose: ng/kg per min. Titrate by ng/kg/min every days until goal of ng/kg/min is reached. Discharge dose: ng per kg per min. Concentration: ng/mL Choose one diluent (0.9% Sodium Chloride will be used if not box is checked): Sterile Water for injection 0.9% Sodium Chloride for injection Pump: 2 CADD-Legacy Pumps CVC Care: Dressing change every days Per IV standard of care IV infusion continuous over 24 hours Initial dose: ng/kg per min. Titrate by ng/kg/min every days until goal of ng/kg/min is reached. Discharge dose: ng per kg per min. Concentration: ng/mL Pump: 2 CADD-Legacy Pumps CVC Care: Dressing change every days Per IV standard of care Dispense one month of drug and supplies. Patient dosing Weight Kg/lb Dispense one month of drug and supplies Patient dosing Weight Kg/lb Dispense one month of drug and supplies. Patient dosing weight Kg/lb IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the named addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure under applicable law. If it is received by anyone other than the named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to disposal of the transmitted material. In no event should such material be read or IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the named addressee and may contain material that is confidential, privileged, proprietary or exampt from disclosure under applicable law. If it is received by anyone other than the named retained anyoneshould other immediately than the named by express the sender to the named Pulmonary 031014 addressee, theby recipient notifyadressee, the senderexcept at the address andauthority telephoneofnumber set forth herein andaddressee. obtain instructions as to Arterial disposalHypertension of the transmitted material. In no even should such material be read or retained by anyone other than the named addressee, except by express authority of the sender to the named addressee. Pulmonary Arterial Hypertension 031014