DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11077 (01/09)
STATE OF WISCONSIN DHS 107.10(2), Wis. Admin. Code
PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS), INCLUDING CYCLOOXYGENASE INHIBITORS
Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Preferred Drug List (PA/PDL) for NonSteroidal Anti-Inflammatory Drugs (NSAIDs), Including Cyclo-oxygenase Inhibitors, Completion Instructions, F-11077A. Pharmacy providers are required to have a completed PA/PDL for NSAIDs, Including Cyclo-oxygenase Inhibitors, form 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 2. Date of Birth -- Member
SECTION II -- PRESCRIPTION INFORMATION 4. Drug Name 6. Date Prescription Written 5. Strength 7. Directions for Use
8. Name -- Prescriber
9. National Provider Identifier (NPI)
10. Address and Telephone Number -- Prescriber (Street, City, State, ZIP+4 Code, and Telephone Number)
SECTION III -- CLINICAL INFORMATION FOR NON-PREFERRED NSAIDs, INCLUDING CYCLO-OXYGENASE INHIBITORS 11. Diagnosis -- Primary Code and / or Description 12. Has the member tried two preferred generic NSAIDs and experienced a treatment failure or had an adverse drug reaction? If yes, circle the two failed, preferred generic NSAIDs that were taken. Preferred drugs: diclofenac flurbiprofen ibuprofen indomethacin ketoprofen ketorolac meloxicam nabumetone naproxen piroxicam List in the space provided the specific details of the treatment failure(s) or adverse drug reaction(s) and the approximate dates the preferred generic NSAIDs were taken.
PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS), INCLUDING CYCLO-OXYGENASE INHIBITORS F-11077 (01/09)
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SECTION III -- CLINICAL INFORMATION FOR NON-PREFERRED NSAIDs, INCLUDING CYCLO-OXYGENASE INHIBITORS (Cont.) 13. Indicate whether or not the member has any of the following risk factors. A. Is he or she over 60 years of age? Yes No B. Is he or she currently taking anti-coagulants? Yes No C. Does the member have a history of gastrointestinal (GI) ulcers or bleeding? Yes No 14. SIGNATURE -- Prescriber 15. Date Signed
SECTION IV -- FOR PHARMACY PROVIDERS USING STAT-PA 16. National Drug Code (11 Digits) 18. NPI 19. 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.) 20. Patient Location (Use patient location code "0" [Not specified], "1" [Home], "4" [Long Term / Extended Care], "7" [Skilled Care Facility], or "10" [Outpatient].) 21. Assigned PA Number 22. Grant Date 23. Expiration Date 24. Number of Days Approved 17. Days' Supply Requested (Up to 365 Days)
SECTION V -- ADDITIONAL INFORMATION 25. Include any additional information in the space below. Submit additional information on a separate sheet if necessary.