Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11305 (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 CROHN'S DISEASE
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 Crohn's Disease Instructions, F-11305A. Pharmacy providers are required to have a completed PA/PDL for Cytokine and CAM Antagonist Drugs for Crohn's Disease 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 2. Date of Birth -- Member

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 5. Strength 7. Directions for Use 9. National Provider Identifier

SECTION III -- CLINICAL INFORMATION FOR CROHN'S DISEASE 12. Diagnosis -- Primary Code and / or Description 13. 14. 15. 16. Does the member have a diagnosis of Crohn's disease? Does the member have moderate to severe symptoms of Crohn's disease? Is the prescription written by a gastroenterologist or through a gastroenterology consultation? Has the member received two or more of the drugs listed below and taken each drug 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

Yes

No

If yes, circle the drugs the member received. Indicate the dose of the drugs, specific details about the treatment failures or adverse drug reactions, and the approximate dates the drugs were taken in the space below. azathioprine corticosteroids methotrexate sulfasalazine 5-aminosalicylic (5-ASA) 6-mercaptopurine (6MP)

17. SIGNATURE -- Prescriber

18. Date Signed

Continued

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR CYTOKINE AND CELL ADHESION MOLECULE (CAM) ANTAGONIST DRUGS FOR CROHN'S DISEASE F-11305 (10/08)

Page 2 of 2

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.

Reset Form