Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-00080A (06/09)

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 DRUG ATTACHMENT FOR BYETTA AND SYMLIN 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 a 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. Attach the completed Prior Authorization Drug Attachment for Byetta and Symlin form, F-00080, to the Prior Authorization Request Form (PA/RF), F-11018, and physician prescription (if necessary), and send it to ForwardHealth. Providers may submit PA requests by fax to ForwardHealth at (608) 221-8616 or by mail 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 -- 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. Element 3 -- Date of Birth Enter the member's date of birth in MM/DD/CCYY format.

SECTION II -- PRESCRIPTION INFORMATION Element 4 -- Drug Name and Strength Check the name and strength of drug. Element 5 -- Date Prescription Written Enter the date that the prescription was written. Element 6 -- Directions for Use Enter the directions for use of the drug. Element 7 -- Name -- Prescriber Enter the name of the prescriber. Element 8 -- Prescriber National Provider Identifier Enter the 10-digit National Provider Identifier of the prescriber.

PRIOR AUTHORIZATION DRUG ATTACHMENT FOR BYETTA AND SYMLIN COMPLETION INSTRUCTIONS F-00080A (06/09)

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Element 9 -- Address -- Prescriber Enter the address (street, city, state, and ZIP+4 code) of the prescriber. Element 10 -- Telephone Number -- Prescriber Enter the telephone number, including area code, of the prescriber. SECTION III -- CLINICAL INFORMATION Providers are required to complete Section III and either Section III A or III B before signing and dating the form. Element 11 -- Diagnosis Code and Description Enter the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code and description most relevant to the drug requested. The ICD-9-CM diagnosis code must correspond with the ICD-9-CM description. Element 12 Enter member's last Hemoglobin A1c (HbA1c) test results. Element 13 -- Date Member's HbA1c Measured Enter the date of the HbA1c test from Element 12. Element 14 Indicate whether or not the member is using the medication for weight loss. Element 15 Indicate whether or not the member is currently using Byetta. Element 16 Indicate whether or not the member is currently using Symlin.
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SECTION III A -- CLINICAL INFORMATION FOR BYETTA

Element 17 Indicate whether or not the member has a diagnosis of Type II Diabetes. Element 18 Indicate whether or not the member is at least 18 years old. Element 19 Indicate whether or not the member is currently taking a sulfonylurea. If yes, indicate the drug name, dose, and directions for use. Element 20 Indicate whether or not the member was unable to tolerate the maximum dose of a sulfonylurea due to a clinically significant adverse drug reaction. If yes, list the drug name, the dose the member was able to titrate to, and the adverse reaction that occurred. Element 21 Indicate whether or not the member has failed to achieve adequate glycemic control at the maximum dose of a sulfonylurea. If yes, indicate the drug on which the member failed, the dose, and directions for use. Element 22 Indicate whether or not the member is currently taking metformin. If yes, indicate the dose and directions for use. Element 23 Indicate whether or not the member is unable to tolerate the maximum dose of metformin due to a clinically significant adverse drug reaction. If yes, list the dose the member was able to titrate to, and the adverse reaction that occurred. Element 24 Indicate whether or not the member has failed to achieve adequate glycemic control at the maximum dose of metformin. If yes, indicate the dose and directions for use. Element 25 Indicate whether or not the member is currently taking a thiazolidinedione. If yes, indicate the drug name, dose, and directions for use. Element 26 Indicate whether or not the member is unable to tolerate the maximum dose of a thiazolidinedione due to a clinically significant adverse drug reaction. If yes, list the drug name, the dose the member was able to titrate to, and the adverse reaction that occurred.

PRIOR AUTHORIZATION DRUG ATTACHMENT FOR BYETTA AND SYMLIN COMPLETION INSTRUCTIONS F-00080A (06/09)

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Element 27 Indicate whether or not the member has failed to achieve adequate glycemic control at the maximum dose of a thiazolidinedione. If yes, indicate the drug on which the member failed, the dose, and directions for use. SECTION III B -- CLINICAL INFORMATION FOR SYMLIN® Element 28 Indicate whether or not the member is currently taking insulin to control Type I Diabetes. Element 29 Indicate whether or not the member is currently taking insulin to control Type II Diabetes. Element 30 Indicate whether or not the member is at least 15 years old. Element 31 Indicate whether or not the member is currently using an insulin pump. Element 32 If the member is currently taking insulin, indicate each type of insulin he or she is taking and include the number of units and dosing frequency for each type. Element 33 Indicate whether or not the member has gastroparesis. Element 34 Indicate whether or not the member has hypoglycemia unawareness. Element 35 Indicate whether or not the member has required emergency treatment for severe hypoglycemia in the past six months. If yes, list how many different occasions he or she required emergency treatment in the past six months.

SECTION IV -- AUTHORIZED SIGNATURE Element 36 -- Signature -- Prescriber The prescriber is required to complete and sign this form. Element 37 -- Date Signed Enter the month, day, and year the form was signed in MM/DD/CCYY format.

SECTION V -- ADDITIONAL INFORMATION Element 38 Indicate any additional information in the space provided. Additional diagnostic and clinical information explaining the need for the drug requested may be included here.