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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11304 (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 / PREFERRED DRUG LIST (PA/PDL) FOR CYTOKINE AND CELL ADHESION MOLECULE (CAM) ANTAGONIST DRUGS FOR ANKYLOSING SPONDYLITIS
Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis Completion Instructions, F-11304A. Pharmacy providers are required to have a completed PA/PDL for Cytokine and CAM Antagonist Drugs for Ankylosing Spondylitis form signed by the prescriber before calling Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) or submitting a paper PA request. SECTION I -- MEMBER INFORMATION 1. Name -- Member (Last, First, Middle Initial) 3. Member Identification Number SECTION II -- PRESCRIPTION INFORMATION 4. Drug Name 6. Date Prescription Written 8. Name -- Prescriber 10. Address -- Prescriber (Street, City, State, ZIP+4 Code) 11. Telephone Number -- Prescriber SECTION III -- CLINICAL INFORMATION FOR ANKYLOSING SPONDYLITIS 12. Diagnosis -- Primary Code and / or Description 13. 14. 15. 16. Does the member have a diagnosis of ankylosing spondylitis? Is the prescription written by a rheumatologist or through a rheumatology consultation? Does the member have moderate to severe axial symptoms of ankylosing spondylitis? Has the member received one or more of the drugs listed below for at least three consecutive months and failed to achieve an adequate response or a reduction in symptoms or experienced a clinically significant adverse drug reaction? Yes Yes Yes No No No 5. Strength 7. Directions for Use 9. National Provider Identifier 2. Date of Birth -- Member

Yes

No

If yes, circle the drug(s) the member received. Indicate the dose of the drug(s), specific details about the treatment failure(s) or adverse drug reaction(s), and the approximate dates the drug(s) was taken in the space below. corticosteroids leflunomide methotrexate NSAID or COX-2 sulfasalazine

17. SIGNATURE -- Prescriber

18. Date Signed

Continued

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR CYTOKINE AND CELL ADHESION MOLECULE (CAM) ANTAGONIST DRUGS FOR ANKYLOSING SPONDYLITIS F-11304 (10/08)

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SECTION IV -- FOR PHARMACY PROVIDERS USING STAT-PA 19. National Drug Code (11 digits) 21. National Provider Identifier 22. 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.) 23. Patient Location (Use patient location code "0" [Not specified], "1" [Home], "4" [Long Term / Extended Care], "7" [Skilled Care Facility], or "10" [Outpatient].) 24. Assigned PA Number 25. Grant Date 26. Expiration Date 27. Number of Days Approved 20. Days' Supply Requested (Up to 365 Days)

SECTION V -- ADDITIONAL INFORMATION 28. Include any additional diagnostic and clinical information explaining the need for the drug requested.

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