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Example Referral Form

This example Referral Form is being provided by United Therapeutics Corporation for informational purposes only. Use of the Referral Form is not a guarantee of coverage or reimbursement. It is the responsibility of the healthcare provider to determine coverage and reimbursement parameters and appropriate coding for specific patients and procedures. The information contained in the form is for illustrative purposes only and is not intended to be a substitute or an influence on the independent medical judgment of the healthcare provider.

Orenitram referral form sample patient information

Please provide complete patient information. It is helpful to include the contact information for a caregiver or family member.

Orenitram referral form sample insurance information

To avoid delays in the approval process, please provide complete insurance information.

Orenitram referral form signature example

The patient’s signature is not required to process the Referral Form; however, it is needed to authorize ASSIST to provide access and support and arrange other services with a Specialty Pharmacy.

Patients can sign up for the Orenitram Patient Support Program. After Referral Form approval, your patients will receive information about the programs and services offered.

Orenitram referral form sample prescription information

Along with your information, please include the preferred method of contacting your office.

Orenitram referral form sample patient disease information

Include all requested patient disease information.

Orenitram referral form sample prescription information

A TID dosing schedule is recommended, as Orenitram is best tolerated when taken every 8 hours.

Be sure to check all dosing strengths, as patients may require different strengths as they titrate to maximum tolerated doses.

The Specialty Pharmacy will generate a dosing sheet from initial prescription up to the goal dose specified.

Select either the established home healthcare nurse schedule or customize the schedule/format using the second, write-in option.

Orenitram referral form sample physician signature

Physician signature is required before submitting the form.

Orenitram referral form sample optional side effect management

You can provide information about your preferred methods for managing side effects for your patients in this section. Instructions listed will be communicated to the Specialty Pharmacy.

Be sure to specify all recommended treatments for side effect management. This allows the Specialty Pharmacy to discuss these treatments with the patient.

You can request specific support (for example, additional in-home nurse visits for education on specific topics).

Orenitram referral form fax cover sheet sample

Contact ASSIST with any questions.

Important Safety Information

Contraindications

  • Avoid use of Orenitram in patients with severe hepatic impairment (Child Pugh Class C) due to increases in systemic exposure.

Warnings and Precautions

  • Abrupt discontinuation or sudden large reductions in dosage of Orenitram may result in worsening of PAH symptoms.
  • The Orenitram tablet shell does not dissolve. In patients with diverticulosis, Orenitram tablets can lodge in a diverticulum.

Adverse Reactions

  • In the 12-week, placebo-controlled, monotherapy study, and an event-driven, placebo-controlled, combination therapy study, adverse reactions that occurred at rates at least 5% higher on Orenitram than on placebo included headache, diarrhea, nausea, vomiting, flushing, pain in jaw, pain in extremity, hypokalemia, abdominal discomfort, and upper abdominal pain.

Drug Interactions

  • Co-administration of Orenitram and the CYP2C8 enzyme inhibitor gemfibrozil increases exposure to treprostinil; therefore, Orenitram dosage reduction may be necessary in these patients.

Specific Populations

  • Animal reproductive studies with Orenitram have shown an adverse effect on the fetus. There are no adequate and well-controlled studies with Orenitram in pregnant women.
  • It is not known whether treprostinil is excreted in human milk or if it affects the breastfed infant or milk production.
  • Safety and effectiveness of Orenitram in pediatric patients have not been established.
  • Use of Orenitram in patients aged 65 years and over demonstrated slightly higher absolute and relative adverse event rates compared to younger patients. Caution should be used when selecting a dose for geriatric patients.
  • There is a marked increase in the systemic exposure to treprostinil in hepatically impaired patients.

Indication

Orenitram is a prostacyclin mimetic indicated for treatment of pulmonary arterial hypertension (PAH) (WHO Group 1) to delay disease progression and to improve exercise capacity. The studies that established effectiveness included predominately patients with WHO functional class II-III symptoms and etiologies of idiopathic or heritable PAH (66%) or PAH associated with connective tissue disease (26%).

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Please see Full Prescribing Information and Patient Information for Orenitram.

For additional information, call 1-877-UNITHER (1-877-864-8437).

TID=3 times daily.