Letairis® (ambrisentan) referrals
Please print and complete the forms below. Once completed, fax to the number indicated on the form.
Required forms for Letairis® (ambrisentan):
Please complete the following and fax to the number indicated on the form.
- Ambrisentan REMS Enrollment Form - for patients new to therapy only
- Generic Prescription Enrollment Form
- Brand Prescription Enrollment Form
- Calcium channel blocker statement
- Statement of Pulmonary Arterial Hypertension Diagnosis
Additional forms that may be required for Ambrisentan:
Some patients’ payers may also require the following. Please contact Accredo for details at 888-200-2811.
- Clinical Documentation Requirements/Fax Transmittal Form
- Statement in Relation to Lung Disease – for patients with certain lung disorders only
- Statement in Relation to Sleep Apnea – for patients with a medical history of sleep apnea
- Statement of Transition - for 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.