Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11303 (10/08)

STATE OF WISCONSIN HFS 107.10(2), 152.06(3)(h), Wis. Admin. Code HFS 153.06(3)(g), 154.06(3)(g), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR ELIDEL® AND PROTOPIC®
INSTRUCTIONS: Type or print clearly. Before completing this form, read the Prior Authorization/Preferred Drug List (PA/PDL) for ® ® Elidel and Protopic Completion Instructions, F-11303A. Pharmacy providers are required to have a completed PA/PDL for Elidel and Protopic signed by the prescriber before calling Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) or submitting a paper PA request. Providers may call ForwardHealth at (800) 947-9627 with questions. SECTION I -- MEMBER INFORMATION 1. Name -- Member (Last, First, Middle Initial) 3. Member Identification Number SECTION II -- PRESCRIPTION INFORMATION 4. Drug Name 6. Date Prescription Written 8. Name -- Prescriber 5. Strength 7. Directions for Use 9. National Provider Identifier 2. Date of Birth -- Member
® ®

10. Address and Telephone Number -- Prescriber (Street, City, State, ZIP+4 Code, and Telephone Number) SECTION III -- CLINICAL INFORMATION FOR ELIDEL® AND PROTOPIC® 11. Diagnosis -- Primary Code and / or Description 12. Is the prescription for Elidel or Protopic written by a dermatologist or an allergist? 13. Is the member over two years of age? 14. Is the member immunocompromised? 15. Has the member taken an antiretroviral or antineoplastic agent within the past two years? 16. Has the member experienced a treatment failure or a clinically significant adverse drug reaction to a topical corticosteroid in the past 183 days? If "yes," list the topical corticosteroid and the approximate dates taken.
® ®

Yes Yes Yes Yes

No No No No

Yes

No

17. Has the member received treatment with Elidel or Protopic in the past 183 days and achieved a measurable therapeutic response? 18. SIGNATURE -- Prescriber

®

®

Yes 19. Date Signed

No

Continued

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR ELIDEL AND PROTOPIC F-11303 (10/08)

®

®

Page 2 of 2

SECTION IV -- FOR PHARMACY PROVIDERS USING STAT-PA 20. National Drug Code (11 Digits) 22. National Provider Identifier 23. Date of Service (MM/DD/CCYY) (For STAT-PA requests, the date of service may be up to 31 days in the future and / or up to 14 days in the past.) 24. Patient Location (Use patient location code "0" [Not Specified], "1" [Home], "4" [Long Term / Extended Care], "7" [Skilled Care Facility], or "10" [Outpatient].) 25. Assigned Prior Authorization Number 26. Grant Date 27. Expiration Date 28. Number of Days Approved 21. Days' Supply Requested (Up to 183 Days)

SECTION V -- ADDITIONAL INFORMATION 29. Include any additional information in the space below. Additional diagnostic and clinical information explaining the need for the product requested may be included here.

Reset Form