Free ForwardHealth Prior Authorization Drug Attachment for Byetta and Symlin, F-00080 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-00080 (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
Instructions: Type or print clearly. Before completing this form, read the Prior Authorization Drug Attachment for Byetta and Symlin Completion Instructions, F-00080A. SECTION I -- MEMBER INFORMATION 1. Name -- Member (Last, First, Middle Initial) 2. Member Identification Number 3. Date of Birth

SECTION II -- PRESCRIPTION INFORMATION 4. Drug Name and Strength (Check One) SymlinPen 60 SymlinPen 120 5. Date Prescription Written 7. Name -- Prescriber 9. Address -- Prescriber (Street, City, State, ZIP+4 Code) Symlin 5 ml vial Byetta 5 mcg Byetta 10 mcg

6. Directions for Use 8. Prescriber National Provider Identifier 10. Telephone Number -- Prescriber

SECTION III -- CLINICAL INFORMATION Providers are required to complete Section III and either Section III A or III B before signing and dating this form. 11. Diagnosis Code and Description 12. State the member's most current HbA1c. % 14. Is the member using the medication for weight loss? 15. Is the member currently using Byetta? 16. Is the member currently using Symlin? SECTION III A -- CLINICAL INFORMATION FOR BYETTA® 17. Does the member have a diagnosis of Type II Diabetes? 18. Is the member at least 18 years old? 19. Is the member currently taking a sulfonylurea? If yes, indicate the drug name, dose, and directions for use in the space provided. Yes Yes Yes No No No 13. Date Member's HbA1c Measured Yes Yes Yes No No No

20. Is the member unable to tolerate the maximum dose of a sulfonylurea due to a clinically significant adverse drug reaction? If yes, indicate the drug name, dose, and adverse reaction in the space provided.

Yes

No

Continued

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

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SECTION III A -- CLINICAL INFORMATION FOR BYETTA® (Continued) 21. Has the member failed to achieve adequate glycemic control at the maximum dose of a sulfonyurea? If yes, indicate the drug, dose, and directions for use in the space provided. Glyburide dose Glipizide dose Glimepiride dose 22. Is the member currently taking metformin? directions for use directions for use directions for use

Yes

No

Yes

No

If yes, indicate the dose and directions for use in the space provided.

23. Is the member unable to tolerate the maximum dose of metformin due to a clinically significant adverse drug reaction? If yes, indicate the dose and adverse reaction in the space provided.

Yes

No

24. Has the member failed to achieve adequate glycemic control at the maximum dose of metformin? If yes, indicate the dose and directions for use in the space provided.

Yes

No

25. Is the member currently taking a thiazolidinedione? If yes, indicate the drug name, dose, and directions for use in the space provided.

Yes

No

26. Is the member unable to tolerate the maximum dose of a thiazolidinedione due to a clinically significant adverse drug reaction? If yes, indicate the drug name, dose, and adverse reaction in the space provided.

Yes

No

27. Has the member failed to achieve adequate glycemic control at the maximum dose of a thiazolidinedione? If yes, indicate the drug, dose, and directions for use in the space provided. Actos dose Avandia dose directions for use directions for use

Yes

No

Continued

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

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SECTION III B -- CLINICAL INFORMATION FOR SYMLIN® 28. Is the member taking insulin for Type I Diabetes? 29. Is the member taking insulin for Type II Diabetes? 30. Is the member at least 15 years old? 31. Is the member using an insulin pump? 32. If the member is taking insulin, indicate their regimen in the space provided. Insulin type Insulin type Number of Units Number of Units

Yes Yes Yes Yes Directions for Use Directions for Use

No No No No

Number of Units Directions for Use Insulin type 33. Does the member have gastroparesis? Yes 34. Does the member have hypoglycemia unawareness? Yes 35. Has the member required emergency treatment for severe hypoglycemia in the past six months? Yes If yes, how many times? SECTION IV -- AUTHORIZED SIGNATURE 36. SIGNATURE -- Prescriber

No No No

37. Date Signed

SECTION V -- ADDITIONAL INFORMATION 38. Additional diagnostic and clinical information explaining the need for the drug requested may be included below.

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