Please print and complete the forms below. Once completed, fax to the number indicated on the form.
Referral forms for Pulmonary Arterial Hypertension (PAH):
- Uptravi® (selexipag) Therapy Referral Form
- Clinical Documentation Requirements/Fax Transmittal Form
- Calcium channel blocker statement
- Statement of Pulmonary Arterial Hypertension Diagnosis
- Statement in Relation to Lung Disease - for patients with certain lung disorders
- Statement in Relation to Sleep Apnea - if clinical notes indicate that pt has a Hx of sleep apnea
- Statement of Transition - for those patients transitioning from another PAH therapy
Getting your patient started on PAH therapy
Pulmonary arterial hypertension (PAH) is characterized as WHO Group 1. The diagnosis of PAH requires 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.
Accredo has developed a checklist to assist you in completing the required clinical documentation for insurance approval for your PAH patients. This checklist is a tool to help remind you everything you need to submit along with the therapy referral form. Our experience has shown that patients get approved quicker when all of the required documentation is submitted along with the referral form. In certain instances we may require additional supporting documentation when there is a presence of other disease comorbidities for example.
Please note: the checklist is only a tool and is not required to be submitted along with the referral form and the clinical documentation.