[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-283926-105":53,"doc-detail-283926-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","veletri-epoprostenol-prior-authorization-prescription-review-fax-form","Veletri-epoprostenol - Prior Authorization Prescription Review Fax Form","","Veletri (epoprostenol) prior authorization fax form used to request coverage review for a patient’s prescribed medication. The form collects patient and prescriber details, then asks structured medical questions related to pulmonary arterial hypertension and related conditions, including diagnostic confirmation, functional class, prior therapies, right heart catheterization, and vasodilator testing. It also requires physician signature and date, instructs fax submission, and includes authorization, eligibility, medical necessity, and confidentiality disclaimers.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/veletri-epoprostenol-prior-authorization-prescription-review-fax-form/283926/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/veletri-epoprostenol-prior-authorization-prescription-review-fax-form/283926.png","ImageObject",442,249,{"name":88,"@type":89},"Ethan Miller","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",13,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What is the purpose of this form for Veletri (epoprostenol)?","Question",{"text":109,"@type":110},"The form is completed by the prescriber to request prior authorization coverage review for Veletri when required by the patient’s prescription benefit plan rules.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Which medical topics does Section A ask about?",{"text":114,"@type":110},"Section A asks about indication or diagnosis, whether the patient meets WHO Group 1 PAH criteria, current medication use, right heart catheterization documentation and results, WHO functional class, prior oral and inhaled/parenteral prostacyclin use, calcium channel blocker therapy history, vasodilator testing, and prescriber specialty.",{"name":116,"@type":107,"acceptedAnswer":117},"What happens after the completed form is faxed?",{"text":118,"@type":110},"After faxing the completed form to the provided toll-free number, prescription benefit coverage is determined according to the plan’s rules. The form also states that authorization does not guarantee payment and includes confidentiality and eligibility/medical necessity disclaimers.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},283926,1790022222,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},687207017582,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","PATIENT: Name   Prescriber: Name    \nAddress:   Address    \nCity, State, Zip   City, State, Zip    \nD.O. B.   Phone    \nMember ID:  Fax    \nNPI    \nMedication Requested:   Qty Requested:    \nYour patient’s prescription benefit requires that we review certain requests for coverage with the prescriber. You have prescribed a medication for your patient that requires Prior Authorization before benefit coverage or coverage of additional quantities can be provided. Please complete the following questions then fax this form to the toll free number listed below. Upon receipt of the completed form, prescription benefit coverage will be determined based on the plan’s rules.  \n SECTION A:  Please answer the following questions  \n1. What is the indication or diagnosis?  \n Pulmonary arterial hypertension [PAH] (WHO Group 1)– Please answer questions 2-17  \n Chronic thromboembolic pulmonary hypertension (CTEPH)– Please answer question 17  \n Chronic obstructive pulmonary disease (COPD) in a patient without PAH (WHO Group 1) .  \n All other indications or diagnosis – Please specify    \n2. Yes No Does the patient have WHO Group 1 PAH?  \n3. Yes No Is the patient currently receiving the requested medication?  \n4. Yes No Is documentation being provided to confirm that the patient has had a right heart catheterization?  \n5. Yes No Did the results of the right heart catheterization confirm the diagnosis of WHO Group  \n1 PAH?  \n6. Yes No Has the patient had a right heart catheterization?  \n7. Yes No Is the patient in Class III or IV of the WHO classification of functional status?  \n8. Yes No Is the patient in Class II of the WHO classification of functional status?  \n9. Yes No Has the patient tried or is the patient currently receiving one oral agent for PAH?  \n10. Yes No Has the patient tried one inhaled or parenteral prostacyclin product for PAH?  \n11. Yes No Does the patient have idiopathic PAH?  \n12. Yes No Has the patient tried one calcium channel blocker (CCB) therapy?  \n13. Yes No Is the patient unable to take calcium channel blocker therapy? Note: examples of reasons a patient cannot take calcium channel blocker therapy include right heart failure or decreased cardiac output.  \n14. Yes No Did the patient have vasodilator testing?  \n15. Yes No Is the patient unable to undergo a vasodilator test according to the prescriber?  \n16. Yes No Has the patient had an acute response to vasodilator testing that occurred during the right heart catheterization according to the prescriber?  \n17. Yes No Is the medication being prescribed by, or in consultation with, a cardiologist or apulmonologist?  \nPlease document the diagnoses, symptoms, and/or any other information important to this review:  \n SECTION B   Physician Signature  \nPHYSICIAN SIGNATURE DATE  \nFAX COMPLETED FORM TO: 877-251-5896  \nDisclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Benefit and medically necessary with prior  \nDisclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services  \nare rendered. Services must be a covered Health Plan Benefit and medically necessary with prior  \nauthorization as per Plan policy and procedures.  \nConfidentiality: The information contained in this transmission is confidential and may be protected under  \nthe Health Insurance Portability and Accountability Act of 1996. If you are not the intended recipient any use,  \ndistribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us  \nimmediately and destroy this document.","cbCait0PzHsWIO4J","https://ap.wps.com/l/cbCait0PzHsWIO4J","pdf",94725,"English","# Patient and Prescriber Information\n# Section A: Coverage Review Questions\n## Indication/Diagnosis Selection\n## Yes/No Clinical Criteria (Questions 2-16)\n## Prescriber Specialty Question (17)\n# Document Clinical Details for Review\n# Section B: Physician Signature and Date\n# Submission Instructions and Disclaimers","[{\"question\":\"What is the purpose of this form for Veletri (epoprostenol)?\",\"answer\":\"The form is completed by the prescriber to request prior authorization coverage review for Veletri when required by the patient’s prescription benefit plan rules.\"},{\"question\":\"Which medical topics does Section A ask about?\",\"answer\":\"Section A asks about indication or diagnosis, whether the patient meets WHO Group 1 PAH criteria, current medication use, right heart catheterization documentation and results, WHO functional class, prior oral and inhaled/parenteral prostacyclin use, calcium channel blocker therapy history, vasodilator testing, and prescriber specialty.\"},{\"question\":\"What happens after the completed form is faxed?\",\"answer\":\"After faxing the completed form to the provided toll-free number, prescription benefit coverage is determined according to the plan’s rules. The form also states that authorization does not guarantee payment and includes confidentiality and eligibility/medical necessity disclaimers.\"}]","Veletri-epoprostenol - Prior Authorization Prescription Review Fax Form | PDF",1789622579]