Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-00081A (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 SUBOXONE AND SUBUTEX 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 Suboxone and Subutex form, F-00081, 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 Check the name of drug prescribed. Element 5 -- Drug Strength Check the strength of drug in milligrams. Element 6 -- Date Prescription Written Enter the date that the prescription was written. Element 7 -- Refills Enter the number of refills. Element 8 -- Directions for Use Enter the directions for use of the drug.

PRIOR AUTHORIZATION DRUG ATTACHMENT FOR SUBOXONE AND SUBUTEX COMPLETION INSTRUCTIONS F-00081A (06/09)

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Element 9 -- Name -- Prescriber Enter the name of the prescriber. Element 10 -- Prescriber National Provider Identifier Enter the 10-digit National Provider Identifier (NPI) of the prescriber. Element 11 -- Address -- Prescriber Enter the address (street, city, state, and ZIP+4 code) of the prescriber. Element 12 -- Telephone Number -- Prescriber Enter the telephone number, including area code, of the prescriber. SECTION IIIA -- CLINICAL INFORMATION This section must be completed for all requests for Suboxone and Subutex. Element 13 -- 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 14 Indicate whether or not the member is at least 16 years old. Element 15 Indicate whether or not the member has been diagnosed with opioid dependence. Element 16 Indicate whether or not the member is currently nursing. Element 17 Check yes if the prescriber is a Drug Addiction Treatment Act (DATA 2000)-waived physician, and enter "X" DEA number. Check no if prescriber does not participate in this program. Element 18 Indicate whether or not the member is taking other opioids, tramadol, or carisoprodol. Element 19 Indicate whether or not the member has any untreated or unstable psychiatric conditions that may interfere with compliance.

SECTION IIIB -- CLINICAL INFORMATION (Complete for Subutex requests only.) Element 20 Indicate whether or not the member is currently pregnant. Element 21 Indicate whether or not the member is allergic to naloxone. SECTION IV -- ATTESTATION The physician must read and sign the attestation statement for consideration of the PA request. Element 22 -- Signature -- Prescriber The prescriber is required to complete and sign this form. Element 23 -- Date Signed Enter the month, day, and year the form was signed in MM/DD/CCYY format. SECTION V -- ADDITIONAL INFORMATION Element 24 Indicate any additional information in the space provided. Additional diagnostic and clinical information explaining the need for the drug requested may be included here.