Free ForwardHealth Prior Authorization Drug Attachment for Alpha Proteinase Inhibitor, F11056 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11056 (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 DRUG ATTACHMENT FOR ALPHA-1 PROTEINASE INHIBITOR
Instructions: Type or print clearly. Before completing this form, read the Prior Authorization Drug Attachment for Alpha-1 Proteinase Inhibitor Completion Instructions, F-11056A. Refer to the STAT-PA System Instructions, F-11055, for details regarding data entry through the Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) system. Pharmacy providers are required to have a completed Prior Authorization Drug Attachment for Alpha-1 Proteinase Inhibitor form signed by the prescriber before calling 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 2. Date of Birth Member

3.

Member Identification Number

SECTION II PRESCRIPTION INFORMATION 4. Drug Name

5.

Strength

6.

Date Prescription Written

7.

Directions for Use

8.

Name Prescriber

9.

National Provider Identifier (NPI)

10. Address and Telephone Number

SECTION III CLINICAL INFORMATION FOR ALPHA-1 PROTEINASE INHIBITOR 11. Diagnosis -- Primary Code and / or Description

12. Does the member have clinically significant panacinar emphysema due to congenital Alpha-1-Antitrypsin deficiency?

Yes

No

13. SIGNATURE Prescriber

14. Date Signed

SECTION IV FOR PHARMACY PROVIDERS USING STAT-PA 15. National Drug Code (11 Digits) 16. Days' Supply Requested (Up to 186 Days)

17. NPI

18. 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. Assigned Prior Authorization Number

19. Patient Location (Use patient location code "0" [Not specified], "1" [Home], "4" [Long Term / Extended Care], "7" [Skilled Care Facility], or "10" [Outpatient].) 21. Grant Date

22. Expiration Date

23. Number of Days Approved

PRIOR AUTHORIZATION DRUG ATTACHMENT FOR ALPHA-1 PROTEINASE INHIBITOR F-11056 (10/08)

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SECTION V ADDITIONAL INFORMATION 24. Include any additional information in the space below. Additional diagnostic and clinical information explaining the need for the product requested may be included here.

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