Pharmacy Enrollment
Instructions
Pharmacies that dispense ambrisentan must be specially certified and enrolled in the PS-Ambrisentan REMS (even if previously enrolled in the Letairis REMS). To become certified, an authorized representative of the pharmacy must first read the Pharmacy Guide, and then agree to follow the PS-Ambrisentan REMS requirements by completing the applicable Pharmacy Enrollment and Agreement Form.
Overview of online enrollment:

1
Pharmacist Information - The authorized representative will be asked to provide their name, title, and credentials. The authorized representative will also be asked to provide an email and phone number as well as additional information about the best time and way to be contacted.

2
Create Password - The authorized representative will be asked to enter a password to create a program account. Upon creation of the account, the authorized representative will receive an email with a link. Upon clicking on the link in the email, the authorized representative will be asked to log in and complete the enrollment.

3
Pharmacy Type Selection - An authorized representative must select the specific pharmacy type for the pharmacy being enrolled.

4
Pharmacy Information - The authorized representative will enter the pharmacy’s organizational National Provider Identifier (NPI) number. This will be used to obtain most of the information needed for enrollment.

5
Agreement - The authorized representative will be asked to provide their signature. By signing, the authorized representative agrees that the pharmacy will comply with the PS-Ambrisentan REMS requirements for the pharmacy type.

6
Complete - The enrollment will be completed upon agreeing and providing a signature.