Pre-Authorization Request For The Oral Phosphodiesterase 5 (Pde5) Inhibitors (I.e., Sildenafil (Revatio),tadalafil (Adcirca), Etc.) Used For Pulmonary Arterial Hypertension (Pah Form
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1MARYLAND MEDICAID PHARMACYPROGRAM
410-767-1755 OR 1-800-492-5231 OPTION 3
FAX 410-333-5398
PRESCRIBER’S STATEMENT OF MEDICAL NECESSITY
Pre-Authorization Request for the oral phosphodiesterase 5 (PDE5) inhibitors
(i.e., Sildenafil (Revatio),Tadalafil (Adcirca), etc.) used for Pulmonary Arterial Hypertension (PAH)
INCOMPLETE FORMS WILL BE RETURNED
PATIENT INFORMATION
Patient location:
Home
Hospital
Clinic
Office
Other________________________________
Patient Name:________________________________________ Age: _____ DOB:_____________ MA ID#:____________________
Address: _________________________________________________________________________ Tel#_______________________
Is patient enrolled in any clinical study?
Yes
No
List study drug: _______________________________________________
Specify sponsoring organization/drug manufacturer_____________________________________________________________________
Specify purpose of study: _________________________________________________________________________________________
PRESCRIBER INFORMATION
If Drug is being prescribed at unapproved dosage or for an unapproved FDA indication; I certify that off-label use or use of the higher
dosage is medically necessary and that patient is not enrolled in any study involving the requested drug. Such off-label use (related to the
indication and/or dosage regimen) of the drug must be documented in one of the three official compendia (American Hospital Formulary
Service Drug Information, Micromedex/Drugdex Drug Data Base, U.S. Pharmacopeia). I will be supervising the patient’s treatment
accordingly. Supporting medical documentation is kept on file in the patient’s medical record.
Prescriber’s Name:________________________________________ Specialty:________________________ Date:_______________
Address:________________________________________________ Tel.#____________________ Fax:________________________
Signature:_______________________________________________ Degree: _________________ NPI #: ______________________
PRESCRIPTION INFORMATION
Drug/strength prescribed: ______________________________________
Dosage frequency:_____________________________
If prescribed dosage exceeds FDA-approved dosage recommendations of 20mg tid (Revatio), and 40 mg.qd (Adcirca) provide reasons for
deviation from approved standard dosage:
_____________________________________________________________________________________________________________
Prescription Type:
Initiation of Therapy
Continued Therapy
List indication(s) for the prescribed drug:
Pulmonary arterial hypertension (PAH)- WHO Diagnosis Group:
I
II
III
IV
V
Associated Causes for PAH:___________________________________________________________________________________
Check NYHA functional class for severity of the symptoms:
I
II
III
IV
Other: ____________________________________________________________________________________________________
Diagnostic tests:
Pre-treatment pulmonary arterial pressure:
______mmHg at rest
_____mmHg with exercise
Date measured: _______________
Post-treatment pulmonary arterial pressure: ______mmHg at rest
_____mmHg with exercise
Date measured: _______________
Did right heart catheterization and vasodilator trial result in a decrease in pulmonary artery pressure > 10 mm Hg with no change or
increase in cardiac output?
Yes*
No**
* If yes (Responder), has a calcium channel blocker, diuretic, and/or anticoagulation been initiated?
Yes
No
** If no (Non-Responder), list other therapies that had been tried for pulmonary arterial hypertension:
_________________________________________________________________________________________________________________________________________________________
Did patient fail optimal therapy with the vasodilators and diuretics?
Yes
No
Please submit to the Program the patient’s medical history with any pertinent diagnostic test results related to his PAH diagnosis.
Approved length of therapy: From___________ to ____________ Quantity:_______ Days Supply:__________
Denied- Reasons:_____________________________________________________________________________________________
Reviewer’s Initials____________
Date:____________________
Rev. 042010
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