Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11097A (10/08)

STATE OF WISCONSIN

FORWARDHEALTH

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR STIMULANTS AND RELATED AGENTS 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. If necessary, attach additional pages if more space is needed. 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 dispensing physicians 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 Stimulants and Related Agents form, F-11097. Pharmacy providers are required to use the PA/PDL for Stimulants and Related Agents to request PA by 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 by fax to ForwardHealth at (608) 221-8616. 3) For paper PA requests by mail, pharmacy providers should submit a PA/RF and the appropriate PA/PDL form 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, followed by his or her 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. Use the ForwardHealth card or the EVS to obtain the correct member ID.

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR STIMULANTS AND RELATED AGENTS COMPLETION INSTRUCTIONS F-11097A (10/08)

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SECTION II -- PRESCRIPTION INFORMATION If this section is completed, providers do not need to submit a copy of the prescription. Element 4 -- Drug Name and Strength Enter the drug name and strength. Element 5 -- Date Prescription Written Enter the date the prescription was written. Element 6 -- Directions for Use Enter the directions for use of the drug. Element 7 -- Name -- Prescriber Enter the name of the prescriber. Element 8 -- National Provider Identifier (NPI) Enter the prescribing provider's NPI. Element 9 -- Address -- Prescriber Enter the complete address of the prescriber's practice location, including the street, city, state, and ZIP+4 code. Element 10 -- 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 STIMULANTS AND RELATED AGENTS 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 11 -- Diagnosis -- Primary Code and / or Description Enter the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code and/or the description most relevant to the drug requested. The ICD-9-CM diagnosis code must correspond with the ICD-9-CM description. The diagnosis for stimulants must be one of the approved stimulant diagnosis codes. Element 12 Check the appropriate box to indicate if the member has taken a non-preferred drug for more than 30 days outside the ForwardHealth system and had a measurable, therapeutic response. SECTION IIIA -- CLINICAL INFORMATION FOR STRATTERA 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 13 Check the appropriate box to indicate whether or not the member has a diagnosis of attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD) and Tourette's syndrome or a history of tics. Element 14 Check the appropriate box to indicate whether or not the member has a diagnosis of ADD or ADHD and obsessive compulsive disorder. Element 15 Check the appropriate box to indicate whether or not the member has a medical history of substance abuse or misuse. If yes, explain in the space provided. Element 16 Check the appropriate box to indicate whether or not the member has a serious risk of diversion. If yes, explain in the space provided.

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR STIMULANTS AND RELATED AGENTS COMPLETION INSTRUCTIONS F-11097A (10/08)

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Element 17 Check the appropriate box to indicate whether or not the member has experienced a treatment failure or a clinically significant adverse drug reaction to a preferred stimulant(s). If yes, indicate in the space provided the preferred stimulant(s), specific details about the treatment failure or adverse drug reaction, and the approximate dates the preferred drug(s) was taken. SECTION IIIB -- CLINICAL INFORMATION FOR PROVIGIL 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 18 Check the appropriate box to indicate whether or not the member has a diagnosis of narcolepsy, obstructive sleep apnea/hypopnea syndrome, or shift work sleep disorder. Element 19 Check the appropriate box to indicate whether or not the member has a diagnosis of ADD or ADHD. Element 20 Check the appropriate box to indicate whether or not the member has experienced a treatment failure or a clinically significant adverse drug reaction to two preferred stimulants. If yes, indicate in the space provided the preferred stimulants, specific details about the treatment failure or adverse drug reaction, and the approximate dates the preferred drugs were taken. Element 21 Check the appropriate box to indicate whether or not the prescriber has peer-reviewed medical literature to support the proven efficacy of the requested use of Provigil for ADD or ADHD. If yes, indicate in the space provided the medical literature references. SECTION IIIC -- CLINICAL INFORMATION FOR NON-PREFERRED STIMULANTS AND RELATED AGENTS 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 22 Check the appropriate box to indicate whether or not the member has a diagnosis of ADD or ADHD. Element 23 Check the appropriate box to indicate whether or not the member has experienced a treatment failure or a clinically significant adverse drug reaction to a preferred stimulant(s). If yes, indicate in the space provided the preferred stimulant(s), specific details about the treatment failure or adverse drug reaction, and the approximate dates the preferred drug(s) was taken. Element 24 -- Signature -- Prescriber The prescriber is required to complete and sign this form. Element 25 -- Date Signed Enter the month, day, and year the PA/PDL for Stimulants and Related Agents was signed (in MM/DD/CCYY format). SECTION IV -- FOR PHARMACY PROVIDERS USING STAT-PA Element 26 -- National Drug Code Enter the appropriate 11-digit National Drug Code (NDC) for each drug. Element 27 -- Days' Supply Requested Enter the requested days' supply up to 365 days. Element 28 -- NPI Enter the provider's NPI. Element 29 -- Date of Service Enter the requested first date of service (DOS) for the drug 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.

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR STIMULANTS AND RELATED AGENTS COMPLETION INSTRUCTIONS F-11097A (10/08)

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Element 30 -- Patient Location Enter the appropriate National Council for Prescription Drug Programs (NCPDP) 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 31 -- Assigned PA Number Indicate the PA number assigned by the STAT-PA system. Element 32 -- Grant Date Indicate the date the PA was approved by the STAT-PA system. Element 33 -- Expiration Date Indicate the date the PA expires as assigned by the STAT-PA system. Element 34 -- Number of Days Approved Indicate the number of days for which the PA request was approved by the STAT-PA system. SECTION V -- ADDITIONAL INFORMATION Element 35 Indicate any additional information in the space below. Additional diagnostic and clinical information explaining the need for the drug requested may be included here.