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®.
- 1.Fill in the required fields so the specialty pharmacy is able to contact the patient directly.
- 2.Option to indicate the preferred specialty pharmacy on the cover sheet.
- 3.Please select one of the 2 titration dosing instruction options.
- 4.Both the physician's signature and the date are required, as well as a copy of the patient's insurance card.
- 5.Please check the appropriate ICD code.
- 6.Check that the patient has signed, dated, and completed all of the required fields. Note: Enrollment in Actelion Pathways (Section 7 of the form) is recommended but not mandatory.
Note: An alternate form is available for VA patients
UPTRAVI VA Patient Enrollment Form
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 given to patients to help support them throughout treatment by tracking and sharing how they’re feeling with their healthcare team.
This guide highlights dosing instructions, important steps, and information about titration with UPTRAVI for patients.
This guide offers dosing, titration, and pill identification information to help you get your patients started on UPTRAVI, as well as adverse reaction management guidance for PAH therapies targeting the prostacyclin pathway.