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Date: February 20, 2009
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State: Wisconsin
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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11179A (01/09)

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 HYPOGLYCEMICS FOR ADJUNCT THERAPY 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 Hypoglycemics for Adjunct Therapy, F-11179. Pharmacy providers are required to use the PA/PDL for Hypoglycemics for Adjunct Therapy 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 may 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 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.

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR HYPOGLYCEMICS FOR ADJUNCT THERAPY COMPLETION INSTRUCTIONS F-11179A (01/09)

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SECTION II -- PRESCRIPTION INFORMATION If this section is completed, providers do not need to include a copy of the prescription documentation used to dispense the product requested. Element 4 -- Drug Name Enter the drug name. 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 -- Name -- Prescriber Enter the name of the prescriber. Element 9 --National Provider Identifier (NPI) Enter the prescribing provider's NPI for prescriptions for non-controlled substances. Element 10 -- Address and Telephone Number -- Prescriber Enter the complete address of the prescriber's practice location, including the street, city, state, and ZIP+4 code, as well as the telephone number, including the area code, of the office, clinic, facility, or place of business of the prescriber. SECTION IIIA -- CLINICAL INFORMATION FOR BYETTA Include diagnostic and clinical information explaining the need for the product requested. In Elements 11 through 20, check "yes" to all that apply. Element 11 -- 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 correspond with the ICD-9-CM description. Element 12 Check the appropriate box to indicate whether or not the member has a diagnosis of Type II diabetes. Element 13 Check the appropriate box to indicate whether or not the member has failed to achieve adequate glycemic control despite individualized diabetic medication management, such as a sulfonyurea or metformin. If "yes" is checked, indicate the member's current medication therapy and most current Hemoglobin A1c (HbA1c). Element 14 Check the appropriate box to indicate whether or not the member is receiving ongoing medical care from a health care professional trained in diabetes management, such as a certified diabetic educator. SECTION IIIB -- CLINICAL INFORMATION FOR SYMLIN


Element 15 Check the appropriate box to indicate whether or not the member has a diagnosis of Type I or Type II diabetes. Element 16 Check the appropriate box to indicate whether or not the member has failed to achieve adequate glycemic control despite optimal insulin management, including the use of meal time insulin. If "yes" is checked, indicate the member's current medication therapy, including insulin regimen. Element 17 Check the appropriate box to indicate whether or not the member has any of the following: an HbA1c greater than nine percent, recurrent severe hypoglycemia or hypoglycemic unawareness, or a diagnosis of gastroparesis. Indicate the member's most current HbA1c value. If the member has any of these conditions, the PA will be returned. Element 18 Check the appropriate box to indicate whether or not the member is receiving ongoing medical care from a health care professional trained in diabetes management, such as a certified diabetic educator.

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR HYPOGLYCEMICS FOR ADJUNCT THERAPY COMPLETION INSTRUCTIONS F-11179A (01/09)

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Element 19 -- Signature -- Prescriber The prescriber is required to complete and sign this form. Element 20 -- Date Signed Enter the month, day, and year the PA/PDL for Hypoglycemics for Adjunct Therapy was signed (in MM/DD/CCYY format). SECTION IV -- FOR PHARMACY PROVIDERS USING STAT-PA Element 21 -- National Drug Code Enter the appropriate 11-digit National Drug Code (NDC) for each drug. Element 22 -- Days' Supply Requested Enter the requested days' supply. Element 23 -- Provider Number Enter the provider number. Element 24 -- Date of Service Enter the requested first date of service (DOS) for the drug or biologic. For STAT-PA requests, the DOS may be up to 31 days in the future or up to 14 days in the past. Element 25 -- 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

Element 26 -- Assigned PA Number Record the PA number assigned by the STAT-PA system. Element 27 -- Grant Date Record the date the PA was approved by the STAT-PA system. Element 28 -- Expiration Date Record the date the PA expires as assigned by the STAT-PA system. Element 29 -- Number of Days Approved Indicate the number of days for which the STAT-PA request was approved by the STAT-PA system. SECTION V -- ADDITIONAL INFORMATION Element 30 Indicate any additional information in the space provided. Additional diagnostic and clinical information explaining the need for the product requested may also be included here.