Manufacturer
Sandoz Pharmaceuticals, Inc.
Streamline Your Prescription Process with MAP Fax Rx
For efficient, transparent communication and easy tracking, send your prescription through MAP Fax Rx. Your fax will appear in the Message Center under “Rx Faxes”, and once received by the pharmacy, it will be listed under “Referral/Rx Received”. Get Started.
Alternatively, if you are unable to send an electronic referral, you can download the PDFs below and send to us via fax.
Referral forms for Pulmonary Arterial Hypertension (PAH):
- treprostinil Generic Therapy Referral Form
- treprostinil Generic Pharmacy Prepared Therapy Referral Form
- Remodulin® (treprostinil) Brand Therapy Referral Form
- Remodulin® Premixed Brand Therapy Referral Form
Other required forms:
- 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