Print and fill out the UPTRAVI Prescription and Patient Enrollment Form
This form allows you to get your patients started on UPTRAVI. The Patient Enrollment Form is not optimized for mobile devices. Please print, sign, and fax to Actelion Pathways®.
- Fill in the required fields so the specialty pharmacy is able to contact the patient directly.
- Option to indicate the preferred specialty pharmacy on the cover sheet.
- You must check “yes” on the enrollment form for each optional support resource available for your patient.
- Both the physician’s signature and the date are required, as well as a copy of the patient’s insurance card.
- Please check the appropriate ICD code.
- Check that the patient has signed, dated, and completed all of the required fields. Note: Enrollment in Actelion Pathways is recommended but not mandatory.
Note: An alternate form is available for Veteran Affairs (VA) patients UPTRAVI VA Patient Enrollment Form.
Prescribe UPTRAVI online through iAssist
UPTRAVI may now be prescribed through iAssist, a web-based platform that streamlines the prescription and enrollment process. Instead of faxing individual enrollment forms and insurance information, data can be entered in one place online to minimize incomplete forms and multiple submissions.
The Actelion Oral PAH Therapy Co-Pay Program*
Commercially insured and eligible patients will have a maximum $5 monthly co-pay for UPTRAVI†
Call 1-866-ACTELION (1-866-228-3546) to contact an Actelion Pathways Case Manager who can provide your office with more details about this program.
*Applies to patients who have provided consent to services offered by Actelion Pathways. The Actelion Oral PAH Therapy Co-Pay Program is only available for residents of the US and Puerto Rico who are 18 or older and have commercial health insurance with co-pay/co-insurance exceeding $5 per prescription fill per product. Patients ineligible for the Actelion Oral PAH Therapy Co-Pay Program include those enrolled in Medicare, Medicaid, VA/DoD (Tricare), the Indian Health Service, or any other federal- or state-funded healthcare program, or where prohibited by law. The Actelion Oral PAH Therapy Co-Pay Program is not prescription drug coverage or insurance. Actelion reserves the right to terminate or modify this program at any time or without notice. Other terms and conditions apply.
†Up to 13 fills or $20,000 per year.
UPTRAVI Dose Adjustment Phase Guide for patients
This guide helps you set goals and expectations with patients who are starting treatment with UPTRAVI. It can be used as a conversation tool and is available to patients to help them stay on treatment by tracking and sharing how they’re feeling with their healthcare team.
UPTRAVI Adverse Reactions Management Tool and Titration Guide
This guide offers dosing, titration, and pill identification information to help get your patients started with UPTRAVI, as well as adverse reaction management guidance for PAH therapies targeting the prostacyclin pathway.
UPTRAVI Prescribing Information
The full Prescribing Information and Patient Product Information for UPTRAVI.