Individual Plan Pulmonary Arterial Hypertension Medication Aetna Precertification Notification Phone: 1-800-414-2386 FAX: 1-800-408-2386 Precertification Request Form Page 1 of 2 (All fields must be completed and legible for precertification review) Start of treatment: Start date Please indicate: / / Continuation of therapy: Date of last treatment Precertification Requested By: Phone: A. PATIENT INFORMATION First Name: Address: Home Phone: DOB: Allergies: Current Weight: lbs. or B. INSURANCE INFORMATION State: ZIP: Cell Phone: E-mail: kgs Height: inches or cms Does patient have other coverage? If yes, provide ID#: Insured: Medicare: Yes No If yes, provide ID #: C. PRESCRIBER INFORMATION First Name: Address: Phone: Fax: Provider E-mail: Cardiologist / Fax: Last Name: City: Work Phone: Aetna Member ID #: Group #: Insured: Specialty (Check one): / Medicaid: Last Name: City: St Lic #: Office Contact Name: Pulmonologist Yes No Carrier Name: Yes No If yes, provide ID #: M.D. (Check One): D.O. State: NPI #: N.P. P.A. ZIP: UPIN: DEA #: Phone: Other: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION Place of Administration: Self-administered Physician’s Office Outpatient Infusion Center Phone: Center Name: Home Infusion Center Phone: Agency Name: Dispensing Provider/Pharmacy: (Patient selected choice) Physician’s Office Retail Pharmacy Specialty Pharmacy Mail Order Other: Name: Phone: TIN: Administration code(s) (CPT): Fax: PIN: E. PRODUCT INFORMATION Request is for: Adcirca Letairis *Dose: Tracleer Opsumit Frequency: Revatio Adempas Orenitram (Failure to indicate dose and frequency may extend review time) F. DIAGNOSIS INFORMATION - Please indicate primary ICD code and specify any other where applicable. ICD Code: 416.0 Primary pulmonary arterial hypertension 416.8 Other chronic pulmonary heart diseases Other: G. CLINICAL INFORMATION - Required clinical information must be completed in its entirety for all precertification requests. 1. What is the World Health Organization classification of the symptoms of the patient’s pulmonary hypertension? (circle one) 2. What was the mean pulmonary artery pressure documented by right-heart catheterization (RHC) or echocardiography: 3. If the diagnosis is 416.8, then please indicate which condition the PAH is secondary to: a. At rest: mmHg b. With exertion: I II III IV mmHg Chronic thromboembolic pulmonary hypertension (CTEPH) not adequately responsive to anticoagulants or surgical thromboendarterectomy 4. Anorectic Drugs Congenital diaphragmatic hernia Connective tissue diseases Familial pulmonary hypertension Congenital heart disease with shunting HIV infection Portopulmonary hypertension Sarcoidosis Other: Has the patient had an acute vasoreactivity test? Yes No NA-patient has pulmonary hypertension secondary to sarcoidosis, congenital diaphragmatic hernia or chronic thromboembolic pulmonary hypertension If yes, did the patient have a positive acute vasoreactivity test result (defined as a decrease in mPAP (mean pulmonary artery pressure) by at least 10 mm Hg to an absolute level of less than 40 mg Hg without a decrease in cardiac output)? Yes No a. If the patient had a positive acute vasoreactivity test result, does the patient have a documented trial and failure of dihydropyridine or diltiazem? Yes No b. If the patient does not have a documented trial and failure, does the patient have a contraindication to dihydropyridine or diltiazem? 5. If female, is the patient pregnant? Yes No The plan may request additional information or clarification, if needed, to evaluate requests. GR-68683-1 (12-14) Yes No Individual Plan Pulmonary Arterial Hypertension Medication Precertification Request Form Aetna Precertification Notification Phone: 1-800-414-2386 FAX: 1-800-408-2386 Page 2 of 2 (All fields must be completed and legible for precertification review) G. CLINICAL INFORMATION (CONTINUED) - Required clinical information must be completed in its entirety for all precertification requests. Requests for Adcirca, tadalafil, or Revatio, - please also complete the following: Yes No Is the patient concurrently on organic nitrates (for example, isosorbide mononitrate, isosorbide dinitrate, nitroglycerin)? Yes No Is the patient currently utilizing Adcirca? Requests for brand Revatio only Yes No Has the patient failed an adequate trial of one month of generic sildenafil? Requests for Adempas - Please answer the following for all Dx: Yes No Is the patient concurrently on organic nitrates (for example, isosorbide mononitrate, isosorbide dinitrate, nitroglycerin)? Yes No Is the patient on PDE inhibitors (for example, sildenafil, Adcirca, dipyridamole or theophylline)? Yes No Is the patient on nitric oxide donors (for example, amyl nitrate)? For Primary PAH Dx answer the following questions: Yes No Does the patient have a contraindication, intolerance, allergy or failure of an adequate trial of 1 month of Letairis or Tracleer? Yes No Does the patient have a contraindication, intolerance, allergy or failure of an adequate trial of 1 month of sildenafil, Adcirca or Revatio? For PAH Dx secondary to CTEPH answer the following questions: Yes No Does the patient have a documented diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) that is inoperable or has not resolved from surgery? If yes, does the patient have a documented thromboembolic occlusion of the pulmonary vasculature? Yes No Requests for Orenitram Yes No Does the patient have hepatic impairment (Child Pugh Class C or greater)? Yes No Is the patient currently using infused or inhaled vasodilators (epoprostenol, Flolan, Veletri, treprostinil, Remodulin, Tyvaso, or iloprost)? Yes No Will the patient be taking Orenitram with other vasodilators? H. ACKNOWLEDGEMENT Request Completed By (Signature Required): Date: / / Any person who knowingly files a request for authorization of coverage of a medical procedure or service with the intent to injure, defraud or deceive any insurance company by providing materially false information or conceals material information for the purpose of misleading, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. The plan may request additional information or clarification, if needed, to evaluate requests. GR-68683-1 (12-14)