Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11306 (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 PLAQUE PSORIASIS
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 Plaque Psoriasis Completion Instructions, F-11306A. Pharmacy providers are required to have a completed PA/PDL for Cytokine and CAM Antagonist Drugs for Plaque Psoriasis 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 5. Strength 7. Directions for Use 9. National Provider Identifier 2. Date of Birth -- Member

SECTION III -- CLINICAL INFORMATION FOR PLAQUE PSORIASIS 12. Diagnosis -- Primary Code and / or Description 13. Does the member have a diagnosis of plaque psoriasis? 14. Does the member have moderate to severe symptoms of plaque psoriasis involving greater than or equal to 10 percent of his or her body surface area? 15. Does the member have a diagnosis of palmoplantar psoriasis? 16. Is the prescription written by a dermatologist or through a dermatology consultation? 17. Has the member received one or more of the treatments 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 Yes No No No No

Yes

No

If yes, circle the treatment(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 of the treatment(s) in the space below. cyclosporine methotrexate phototherapy Soriatane

18. SIGNATURE -- Prescriber

19. Date Signed

Continued

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR CYTOKINE AND CELL ADHESION MOLECULE (CAM) ANTAGONIST DRUGS FOR PLAQUE PSORIASIS F-11306 (10/08)

Page 2 of 2

SECTION IV -- FOR PHARMACY PROVIDERS USING STAT-PA 20. National Drug Code (11 digits) 22. National Provider Identifier 23. 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.) 24. Patient Location (Use patient location code "0" [Not specified], "1" [Home], "4" [Long Term / Extended Care], "7" [Skilled Care Facility], or "10" [Outpatient].) 25. Assigned PA Number 26. Grant Date 27. Expiration Date 28. Number of Days Approved 21. Days' Supply Requested (Up to 365 Days)

SECTION V -- ADDITIONAL INFORMATION 29. Include any additional diagnostic and clinical information explaining the need for the drug requested.

Reset Form