Pulmonary Arterial Hypertension Medication Precertification

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)