Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11306A (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 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 (HFS 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 PA for certain drugs. 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. Prescribers and pharmacy providers are required to retain a completed copy of the form. INSTRUCTIONS Prescribers are required to complete and sign the Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriasis, F-11306. Pharmacy providers are required to use the PA/PDL for Cytokine and CAM Antagonist Drugs for Plaque Psoriasis to request PA using the Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) system or by submitting a paper PA request. Providers may submit PA requests on a PA/PDL form in one of the following ways: 1) For STAT-PA requests, pharmacy providers should call (800) 947-1197. 2) For paper PA requests by fax, pharmacy providers should submit a Prior Authorization Request Form (PA/RF), F-11018, and the appropriate PA/PDL form to ForwardHealth at (608) 221-8616. 3) For paper PA requests by mail, pharmacy providers should submit a PA/RF, the appropriate PA/PDL form, and supporting documentation to the following address: ForwardHealth Prior Authorization Ste 88 6406 Bridge Rd Madison WI 53784-0088 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 -- Date of Birth -- Member Enter the member's date of birth in MM/DD/CCYY format. Element 3 -- Member Identification Number Enter the member ID. Do not enter any other numbers or letters.

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

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SECTION II -- PRESCRIPTION INFORMATION If this section is completed, providers do not need to include a copy of the prescription documentation used to dispense the product requested. Element 4 -- Drug Name Enter the drug name. Element 5 -- Strength Enter the strength of the drug listed in Element 4. Element 6 -- Date Prescription Written Enter the date the prescription was written. Element 7 -- Directions for Use Enter the directions for use of the drug. Element 8 -- Name -- Prescriber Enter the name of the prescriber. Element 9 -- National Provider Identifier Enter the prescribing provider's National Provider Identifier. Element 10 -- Address -- Prescriber Enter the complete address of the prescriber's practice location, including the street, city, state, and ZIP+4 code. Element 11 -- Telephone Number -- Prescriber Enter the telephone number, including the area code, of the office, clinic, facility, or place of business of the prescriber. SECTION III -- CLINICAL INFORMATION FOR PLAQUE PSORIASIS Include diagnostic and clinical information explaining the need for the product requested. Complete all elements in Section III. Check "yes" or "no" as it applies to each question. Include written documentation as indicated. Element 12 -- Diagnosis -- Primary Code and / or Description Enter the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code and/or description most relevant to the drug requested. The ICD-9-CM diagnosis code must correspond with the ICD-9-CM description. Element 13 Check the appropriate box to indicate whether or not the member has a diagnosis of plaque psoriasis. Element 14 Check the appropriate box to indicate whether or not the member has moderate to severe symptoms of plaque psoriasis involving greater than or equal to 10 percent of his or her body surface area. Element 15 Check the appropriate box to indicate whether or not the member has a diagnosis of debilitating palmoplantar psoriasis. Element 16 Check the appropriate box to indicate whether or not the prescription is written by a dermatologist or through a dermatology consultation. Element 17 Check the appropriate box to indicate whether or not the member has received one or more of the drugs listed on the PA/PDL form 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. If "yes" is checked, circle the drug(s) received. In the space provided, indicate the dose of the drug(s), specific details about the treatment failure(s) or adverse drug reaction(s), and the approximate date(s) the drug(s) was taken.

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

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Element 18 -- Signature -- Prescriber The prescriber is required to complete and sign this form. Element 19 -- Date Signed Enter the month, day, and year the PA/PDL for Cytokine and CAM Antagonist Drugs for Plaque Psoriasis was signed (in MM/DD/CCYY format). SECTION IV -- FOR PHARMACY PROVIDERS USING STAT-PA Element 20 -- National Drug Code Enter the appropriate 11-digit National Drug Code for each drug. Element 21 -- Days' Supply Requested Enter the requested days' supply, up to 365 days. Element 22 -- National Provider Identifier Enter the National Provider Identifier of the pharmacy provider. Element 23 -- Date of Service Enter the requested first date of service (DOS) for the drug or biologic in MM/DD/CCYY format. For STAT-PA requests, the DOS may be up to 31 days in the future or up to 14 days in the past. Element 24 -- Patient Location Enter the appropriate National Council for Prescription Drug Programs patient location code designating where the requested item would be provided/performed/dispensed. Code 0 1 4 7 10 Description Not Specified Home Long Term/Extended Care Skilled Care Facility Outpatient

Element 25 -- Assigned PA Number Record the PA number assigned by the STAT-PA system. Element 26 -- Grant Date Record the date the PA request was approved by the STAT-PA system. Element 27 -- Expiration Date Record the date the PA expires as assigned by the STAT-PA system. Element 28 -- Number of Days Approved Record the number of days for which the PA request was approved by the STAT-PA system. SECTION V -- ADDITIONAL INFORMATION Element 29 Indicate any additional information in the space provided. Additional diagnostic and clinical information explaining the need for the product requested may be included here.