Letairis® (ambrisentan)

Multiple Manufacturers

Send your referral electronically

You can send an electronic referral using our prescriber website MyAccredoPatients.com. Simply register or login and navigate to "Send a Referral" on the dashboard. Once logged in, you will be routed to iAssist, which is Accredo’s electronic referral service. If you are not registered for iAssist, you will be prompted to do so.

Alternatively, if you are unable to send an electronic referral, you can download the PDFs below and send to us via fax.

Required forms for Letairis® (ambrisentan):

This medication has REMS requirements. REMS, or Risk Evaluation and Mitigation Strategy, requirements are put in place to ensure the safe use of certain medications with known risks. The requirements aim to minimize the potential risks while allowing patients to access prescribed medications. For more information about the REMS requirements for patient and prescriber enrollment and to access the enrollment forms, please visit the REMS program website.

Please complete the following and fax to the number indicated on the form.

Getting your patient started on PAH therapy

Pulmonary arterial hypertension (PAH) is characterized as WHO Group 1. The diagnosis of PAH may require confirmation with a complete right heart catherization. The current hemodynamic definition of PAH is a mean pulmonary artery pressure greater than 25mmHg; a pulmonary capillary wedge pressure, or left ventricular end-diastolic pressure less than or equal to 15mmHg; and a pulmonary vascular resistance greater than 3 Wood units.