2019 Virginia Medicaid-FAMISPulmonary Arterial Hypertension (PAH) AgentsPrior Authorization (PA)Kaiser Permanente Health Plan of Mid-Atlantic States, Inc.-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's name, Kaiser Medical ID number, and date of birth accurately.
3. Proceed to the 'Provider Information' section. Indicate if the provider is a pulmonologist or cardiologist, and provide their name, NPI, address, phone number, and fax number.
4. Select whether this is an 'Initial Request' or 'Continuation of Therapy Request'. Choose between 'Standard Review' or 'Expedited Review' based on urgency.
5. In the 'Pharmacy Information' section, enter the pharmacy's name, NPI, phone number, and fax number.
6. Fill out the 'Drug Therapy Requested' section with details for each drug including name, strength, formulation, and sig.
7. Answer the questions in the 'Diagnosis' section regarding Pulmonary Hypertension and age criteria.
8. If applicable, provide clinical rationale for injectable Revatio in the 'Clinical Criteria' section.
9. Complete any additional information required in the 'Provider Sign-Off' section and ensure all signatures are provided before submission.

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