Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11092A (03/09)

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

FORWARDHEALTH

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR GROWTH HORMONE DRUGS COMPLETION INSTRUCTIONS
ForwardHealth requires certain information to enable the programs to authorize and pay for medical services provided to eligible members. Members of ForwardHealth are required to give providers full, correct, and truthful information for the submission of correct and complete claims for reimbursement. This information should include, but is not limited to, information concerning enrollment status, accurate name, address, and member identification number (DHS 104.02[4], Wis. Admin. Code). Under s. 49.45(4), Wis. Stats., personally identifiable information about program applicants and members is confidential and is used for purposes directly related to ForwardHealth administration such as determining eligibility of the applicant, processing prior authorization (PA) requests, or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of PA or payment for the services. The use of this form is mandatory when requesting PA for certain drugs. If necessary, attach additional pages if more space is needed. Refer to the applicable service-specific publications for service restrictions and additional documentation requirements. Provide enough information for ForwardHealth to make a determination about the request. INSTRUCTIONS Prescribers are required to complete and sign the Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs form, F-11092. Pharmacy providers are required to use the PA/PDL for Growth Hormone Drugs form to request PA using the Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) system or by submitting a paper PA request. Prescribers and pharmacy providers are required to retain a completed copy of the form. Providers may submit PA requests on a PA/PDL form in one of the following ways: 1) For STAT-PA requests, pharmacy providers should call (800) 947-1197. 2) For paper PA requests by fax, pharmacy providers should submit a Prior Authorization Request Form (PA/RF), F-11018, and the appropriate PA/PDL form to ForwardHealth at (608) 221-8616. 3) For paper PA requests by mail, pharmacy providers should submit a PA/RF and the appropriate PA/PDL form to the following address: ForwardHealth Prior Authorization Ste 88 6406 Bridge Rd Madison WI 53784-0088 Providers should make duplicate copies of all paper documents mailed to ForwardHealth. The provision of services that are greater than or significantly different from those authorized may result in nonpayment of the billing claim(s). SECTION I -- MEMBER INFORMATION Element 1 -- Name -- Member Enter the member's last name, first name, and middle initial. Use Wisconsin's Enrollment Verification System (EVS) to obtain the correct spelling of the member's name. If the name or spelling of the name on the ForwardHealth identification card and the EVS do not match, use the spelling from the EVS. Element 2 -- Date of Birth -- Member Enter the member's date of birth in MM/DD/CCYY format. Element 3 -- Member Identification Number Enter the member ID. Do not enter any other numbers or letters. Use the ForwardHealth card or the EVS to obtain the correct member ID. SECTION II -- PRESCRIPTION INFORMATION Element 4 -- Drug Name Enter the drug name.

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR GROWTH HORMONE DRUGS COMPLETION INSTRUCTIONS F-11092A (03/09)

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Element 5 -- Strength Enter the strength of the drug listed in Element 4. Element 6 -- Date Prescription Written Enter the date the prescription was written. Element 7 -- Directions for Use Enter the directions for use of the drug. Element 8 -- Diagnosis -- Primary Code and / or Description Enter the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code and/or description most relevant to the drug requested. The ICD-9-CM diagnosis code must match the ICD-9-CM description. Element 9 -- Name -- Prescriber Enter the name of the prescriber. Element 10 --National Provider Identifier (NPI) Enter the prescribing provider's NPI for prescriptions for non-controlled substances. Element 11 -- Address -- Prescriber Enter the complete address of the prescriber's practice location, including the street, city, state, and ZIP+4 code. Element 12 -- Telephone Number -- Prescriber Enter the telephone number, including the area code, of the office, clinic, facility, or place of business of the prescriber. Element 13 -- Signature -- Prescriber The prescriber is required to complete and sign this form. Element 14 -- Date Signed Enter the month, day, and year the PA/PDL for Growth Hormone Drugs form was signed (in MM/DD/CCYY format). SECTION III -- CLINICAL INFORMATION Element 15 Indicate whether or not the member has a diagnosis of Acquired Immune Deficiency Syndrome (AIDS) Wasting Disease or cachexia. SECTION IIIA -- CLINICAL INFORMATION FOR GROWTH HORMONE DRUGS Include diagnostic and clinical information explaining the need for the drug requested. In Elements 15 through 21, check "yes" to all that apply. Element 16 Check the box to indicate whether or not the member has tried and failed a preferred growth hormone drug. Preferred growth hormone drugs include Genotropin, Nutropin, Nutropin AQ, and Norditropin. Element 17 Check the box to indicate whether or not the member's chronological age is under 20 years. Element 18 Check the box to indicate whether or not the member's skeletal age is documented to be under 18 years. Element 19 Check the box to indicate whether or not the prescription was written by an endocrinologist. The prescription must be written by an endocrinologist for the member to begin treatment with a growth hormone drug. Element 20 Check the box to indicate whether or not the member has a diagnosis of growth deficiency. The member must have a diagnosis of growth deficiency to begin treatment with a growth hormone drug. Element 21 Check the box to indicate whether or not the member has a diagnosis of Prader Willi or Turner's Syndrome. If the member has a diagnosis of Prader Willi or Turner's Syndrome, a stimulated growth hormone test is not required.

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR GROWTH HORMONE DRUGS COMPLETION INSTRUCTIONS F-11092A (03/09)

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Element 22 Check the box to indicate whether or not the member had a recent stimulated growth hormone test that demonstrated a clear abnormality. Indicate the test result and normal range. Note: When a STAT-PA request is returned because a member has not had a stimulated growth hormone test, additional information is required for PA review. If the member has a medical condition, such as hypopituitary disease, and a stimulated growth hormone test is not medically indicated, medical records supporting the growth hormone deficiency are required. The medical records should be included with a paper PA request, which includes a completed PA/RF, PA/PDL for Growth Hormone Drugs, and supporting documentation. SECTION IIIB -- CLINICAL INFORMATION FOR SEROSTIM FOR AIDS WASTING DISEASE OR CACHEXIA In Elements 23 through 26, prescribers should indicate "1" if the response to the question is yes. Indicate "2" if the response is no. Element 23 -- Diagnosis The member must be at least 18 years of age and have a diagnosis of Human Immunodeficiency Virus (HIV) to begin treatment with a growth hormone drug. Element 24 -- Member's Current Medical Condition Indicate the member's current medical condition by responding to the clinical information listed in this section. Element 25 -- Evidence of Wasting Syndrome The member must have either an unintentional weight loss of at least 10 percent or a gastrointestinal (GI) obstruction or malabsorption to qualify for treatment with a growth hormone drug. Element 26 All of the clinical information listed must be tried and failed before a member may begin a course of therapy with a growth hormone drug. SECTION IV -- FOR PHARMACY PROVIDERS USING STAT-PA Element 27 -- National Drug Code Enter the appropriate 11-digit National Drug Code for each drug. Element 28 -- Days' Supply Requested Enter the requested days' supply. Element 29 -- NPI Enter the NPI. Element 30 -- Date of Service Enter the requested first date of service (DOS) for the drug in MM/DD/CCYY format. For STAT-PA requests, the DOS may be up to 31 days in the future or up to 14 days in the past. Element 31 -- Patient Location Enter the appropriate National Council for Prescription Drug Programs (NCPDP) patient location code designating where the requested item would be provided/performed/dispensed. Code 0 1 4 7 10 Description Not Specified Home Long Term/Extended Care Skilled Care Facility Outpatient

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR GROWTH HORMONE DRUGS COMPLETION INSTRUCTIONS F-11092A (03/09)

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Element 32 -- Assigned PA Number Record the PA number assigned by the STAT-PA system. Element 33 -- Grant Date Record the date the PA was approved by the STAT-PA system. Element 34 -- Expiration Date Record the date the PA expires as assigned by the STAT-PA system. Element 35 -- Number of Days Approved Record the number of days for which the STAT-PA request was approved by the STAT-PA system. Element 36 Check the box to indicate if additional information is necessary. Submit additional information on a separate sheet.