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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11034 (10/08)

STATE OF WISCONSIN HFS 107.06(2), Wis. Admin. Code HFS 152.06(3)(h), 153.06(3)(g), 154.06(3)(g), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / "J" CODE ATTACHMENT (PA/JCA)
Providers may submit prior authorization (PA) requests with attachments to ForwardHealth by fax at (608) 221-8616 or by mail to ForwardHealth, Prior Authorization, Suite 88, 6406 Bridge Road, Madison, WI 53784-0088. Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/"J" Code Attachment (PA/JCA) Completion Instructions, F-11034A. SECTION I -- MEMBER INFORMATION 1. Name -- Member (Last, First, Middle Initial) 2. Date of Birth -- Member

3. Member Identification Number

SECTION II -- DRUG ORDER INFORMATION 4. Drug Name 5. Strength

6. National Drug Code

7. HCPCS "J" Code

8. Quantity Ordered

9. Date Order Issued

10. Daily Dose

11. Name -- Prescriber

12. National Provider Identifier

13. "Brand Medically Necessary" Yes No If yes, please indicate and describe the adverse reaction, allergic reaction, or actual therapeutic failure in the space provided.

SECTION III -- CLINICAL INFORMATION 14. Diagnosis

15. Changes to Previous Clinical Condition

Continued

PRIOR AUTHORIZATION / "J" CODE ATTACHMENT (PA/JCA) F-11034 (10/08)

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SECTION III -- CLINICAL INFORMATION (Continued) 16. Use (Check One) Compendium standards, such as the United States Pharmacopeia Dispensing Information (USP-DI) or drug package insert, lists the intended use previously identified as an accepted or a [bracketed] indication. The intended use identified above is not listed in compendium standards. Peer-reviewed clinical literature is attached. 17. Dose (Check One) The daily dose and duration are within compendium standards of general prescribing or dosing limits for the indicated use. The daily dose and duration are not within compendium standards of general prescribing or dosing limits for the intended use. Attach peer-reviewed literature that indicates this dose is appropriate or document the medical necessity of this dosing difference. 18. SIGNATURE -- Prescriber 19. Date Signed

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