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How to use or fill out 2019 Virginia Medicaid-FAMISPulmonary Arterial Hypertension (PAH) Agents Prior Authorization with our platform
- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the 'Patient Information' section. Enter the patient's name, Kaiser Medical ID number, and date of birth accurately.
- 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.
- Select whether this is an 'Initial Request' or 'Continuation of Therapy Request'. Choose between 'Standard Review' or 'Expedited Review' based on urgency.
- In the 'Pharmacy Information' section, enter the pharmacy's name, NPI, phone number, and fax number.
- Fill out the 'Drug Therapy Requested' section with details for each drug including name, strength, formulation, and sig.
- Answer the questions in the 'Diagnosis' section regarding Pulmonary Hypertension and age criteria.
- If applicable, provide clinical rationale for injectable Revatio in the 'Clinical Criteria' section.
- Complete any additional information required in the 'Provider Sign-Off' section and ensure all signatures are provided before submission.
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