Free ForwardHealth Prior Authorization Drug Attachment for C-III and C-IV Stimulants and Anti-Obesity Drugs, F11061 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11061 (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 C-III AND C-IV STIMULANTS AND ANTI-OBESITY DRUGS
Instructions: Type or print clearly. Before completing this form, read Prior Authorization Drug Worksheet for C-III and C-IV Stimulants and Anti-Obesity Drugs Completion Instructions, F-11061A. Refer to the STAT-PA System Instructions, F-11055, for details regarding data entry through the STAT-PA system. Pharmacy providers are required to have a completed Prior Authorization Drug Attachment for C-III and C-IV Stimulants and AntiObesity Drugs form signed by the prescriber before calling Specialized Transmission Approval Technology-Prior Authorization (STATPA) 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

10. Address and Telephone Number

SECTION III CLINICAL INFORMATION FOR C-III AND C-IV STIMULANTS AND ANTI-OBESITY DRUGS 11. Diagnosis Primary Code and / or Description

12. Member's Height (inches):

13. Member's Weight (pounds):

14. SIGNATURE Prescriber

15. Date Signed

SECTION IV FOR PHARMACY PROVIDERS USING STAT-PA 16. National Drug Code (11 Digits) 18. National Provider Identifier 17. Days' Supply Requested (Up to 186 Days) 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)

PRIOR AUTHORIZATION DRUG ATTACHMENT FOR C-III and C-IV STIMULANTS AND ANTI-OBESITY DRUGS F-11061 (10/08)

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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 Prior Authorization Number

22. Grant Date

23. Expiration Date

24. Number of Days Approved

SECTION V ADDITIONAL INFORMATION 25. 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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