Free ForwardHealth Prior Authorization Drug Attachment for Provigil Completion Instructions, F-00079A - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-00079A (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 PROVIGIL 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 Provigil form, F-00079, 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 Strength Check the strength of drug in milligrams. Element 5 -- Date Prescription Written Enter the date that the prescription was written. Element 6 -- Refills Enter the number of refills. Element 7 -- Directions for Use Enter the directions for use of the drug. Element 8 -- Name -- Prescriber Enter the name of the prescriber.

PRIOR AUTHORIZATION DRUG ATTACHMENT FOR PROVIGIL COMPLETION INSTRUCTIONS F-00079A (06/09)

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Element 9 -- Prescriber National Provider Identifier Enter the 10-digit National Provider Identifier of the prescriber. Element 10 -- Address -- Prescriber Enter the address (street, city, state, and ZIP+4 code) of the prescriber. Element 11 -- 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 Sections III A, III B, III C, or III D before signing the form. Element 12 -- 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 13 Indicate whether or not the member is at least 16 years old. Element 14 Indicate whether or not the member is currently taking any other stimulants.

SECTION III A -- CLINICAL INFORMATION FOR NARCOLEPSY Element 15 Indicate whether or not the member has a diagnosis of Narcolepsy. Element 16 Indicate whether or not the member has completed a polysomnogram (PSG). If yes, the results from a PSG must be submitted with this PA request for consideration. Element 17 Indicate whether or not the member has taken a Multiple Sleep Latency Test (MSLT). If yes, the results from an MSLT must be submitted with this PA request for consideration.

SECTION III B -- CLINICAL INFORMATION FOR OBSTRUCTIVE SLEEP APNEA/HYPOPNEA SYNDROME Element 18 Indicate whether or not the member has a diagnosis of Obstructive Sleep Apnea/Hypopnea Syndrome (OSAHS). Element 19 Indicate whether or not the member has completed a polysomnogram (PSG). If yes, the results from a PSG must be submitted with this PA request for consideration. Element 20 Indicate the member's Apnea-Hypopnea Index (AHI) in events per hour. Element 21 Indicate whether or not the member has tried Continuous Positive Airway Pressure (CPAP).

SECTION III C -- CLINICAL INFORMATION FOR SHIFT WORK SLEEP DISORDER Element 22 Indicate whether or not the member has a diagnosis of shift work sleep disorder. Element 23 Indicate whether or not the member is a night-shift worker.

PRIOR AUTHORIZATION DRUG ATTACHMENT FOR PROVIGIL COMPLETION INSTRUCTIONS F-00079A (06/09)

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Element 24 Indicate whether or not the member is taking any hypnotics, sleep aids, or other medications that can cause sleepiness. Element 25 Enter the member's current employer, along with his or her weekly work schedule.

SECTION III D -- CLINICAL INFORMATION FOR ATTENTION DEFICIT DISORDER Element 26 Indicate whether or not the member has a diagnosis of Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD). Element 27 Indicate whether or not the member has a medical history of substance abuse or misuse. If yes, explain the substance abused and the current state of the member's usage of that substance. Also include any rehabilitation taken. Element 28 Indicate whether or not the member poses a risk of drug diversion. If yes, explain what the member has done in the past to be considered a risk for diversion. Element 29 Indicate whether or not the member has had a treatment failure or stopped taking Strattera due to a clinically significant adverse drug reaction. If yes, indicate the dates Strattera was taken and the reason for discontinuation.

SECTION IV -- AUTHORIZED SIGNATURE Element 30 -- Signature -- Prescriber The prescriber is required to complete and sign this form. Element 31 -- Date Signed Enter the month, day, and year the form was signed in MM/DD/CCYY format.

SECTION V -- ADDITIONAL INFORMATION Element 32 Indicate any additional information in the space provided. Additional diagnostic and clinical information explaining the need for the drug requested may be included here.