Complete Form in Its Entirety and Fax To: Anthem Blue Cross 866-408-7195

REVIEW REQUEST FOR

Flolan®, Remodulin® – Prostacyclins

Complete form in its entirety and fax to: Anthem Blue Cross 866-408-7195

Provider Data Collection Tool Based on Medical PolicyDRUG.00004

Policy Last Review Date: 02/13/2014 / Policy Effective Date: 04/15/2014 / Provider Tool Effective Date: 04/13/2011

Request Date: //

Initial Request Subsequent Request

Buy and Bill

Individual’s Name: / Date of Birth:
//
Insurance Identification Number: / Individual’s Phone Number:
Primary Diagnosis: / Diagnosis Code(s) (if known): / Individual’s Weight
(lbs) (kg)
Ordering Provider Name & Specialty: / Provider ID Number (if known):
Office Address:
Contact Name and Office Phone Number: / Office Fax Number:
Servicing Provider Name & Specialty(If different than Ordering Provider): / Provider ID Number (if known):
Office Address:
Contact Name and Office Phone Number: / Office Fax Number:
Place of Service: Home Office DialysisCenter OutpatientHospital
Ambulatory Infusion AmbulatoryInfusionCenter Other:
Drug Name/HCPCS Code (if known)
Flolan® J1325 Remodulin® J3285
Veletri® J1325 TYVASO™ J7686
Ventavis® Q4074 Other: / Dose to be administered: (mg/kg)
(ng/kg/min)
(other)
When did the individual first start this drug?
// / Frequency (Days, Wks, Months)
Duration:
(Weeks) / Start Date For This Request:
//

Please check all that apply to the individual:

Pulmonary Arterial Hypertension (PAH)-Folan®, Remodulin®, Ventavis®, Veletri®, TYVASO®

Individual has been diagnosed with pulmonary arterial hypertension (PAH)

The right heart catheterization shows a mean pulmonary artery pressure of mPAP greater than 25mm Hg

The pulmonary capillary wedge pressure (PCWP), left arterial pressure, or left ventricular end-diastolic pressure (LVEDP)

less than or equal to 15mm Hg

The pulmonary ventricular resistance (PVR) greater than 3 Wood units

Individual has New York Heart Association Functional Class III and IV symptoms? If checked, please check all that apply:

Individualidentified within the WHO Group I for pulmonary hypertension

Individual’s pulmonary hypertension associated with connective tissue disorders

Individual’s pulmonary hypertension associated with congenital heart defects

Individual had a favorable response to vasodilators. (a favorable response is defined as a fall in mPAP of at least 10mm Hg to an absolute mPAP of less than 40mm Hg without a decrease in cardiac output, when challenged with inhaled nitric oxide, intravenous epoprostenol or intravenous adenosine)

The disease refractory to treatment with calcium channel blockers

Individual had an unfavorable response to vasodilators

Other:

Remodulin®Only

This is to be administered by continuous subcutaneous infusion

This is to be administered by continuous intravenous infusion

Individual has documented inability to tolerate treatment by subcutaneous infusion

Other:

(2) Other Use(s) (Please submit all supporting documents including labs, progress notes, imaging, etc., for review.)

This request is being submitted:

Pre-Claim

Post–Claim. If checked, please attach the claim or indicate the claim number

I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its designees may perform a routine audit and request the medical documentation to verify the accuracy of the information reported on this form.

Name and Title of Provider or Provider Representative CompletingDate

Form and Attestation (Please Print)*

*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted

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