Free Wisconsin Medicaid STAT-PA Drug Worksheet for Brand Name Ace Inhibitors, HCF 11057 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 11057 (Rev. 08/03)

STATE OF WISCONSIN

WISCONSIN MEDICAID

STAT-PA DRUG WORKSHEET FOR BRAND NAME ACE INHIBITORS
This worksheet is to be used by pharmacists and dispensing physicians only. Generic angiotensin converting enzyme (ACE) inhibitors do not require prior authorization (PA). In addition to the generic ACE inhibitors, the following brand name ACE inhibitors do not require PA: · Captopril. · Enalapril. · Trandolapril. · Moexipril. Name -- Recipient The Specialized Transmission Approval Technology-PA (STAT-PA) system will ask for the following items in the order listed below: GENERAL INFORMATION Wisconsin Medicaid Provider Number Recipient Medicaid Identification Number National Drug Code Prescriber's Drug Enforcement Administration Number Diagnosis Code Use the most appropriate International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code. The decimal is not necessary. Place of Service (Patient Location) Use patient location code "00" (Not Specified), "01" (Home [IVIM Services Only]), "04" (Long Term/Extended Care), "07" (Skilled Care Facility), or "10" (Outpatient). Date of Service The date of service may be up to 31 days in the future, or up to four days in the past. Days' Supply Requested* CLINICAL INFORMATION A. Is the patient currently stabilized or being titrated on an ACE Inhibitor other than captopril, enalapril, trandolapril, or moexipril? If yes, press "1." If no, press "2." ____ 1.) If yes, the PA request will be approved for up to 365 days. 2.) If no, the provider will be asked: Has the recipient tried captopril, enalapril, trandolapril, or moexipril and had an adverse drug reaction? If yes, press "1." If no, press "2." ____ 1.) If yes, the PA request will be approved for up to 365 days. 2.) If no, the provider will receive the following message: "Your prior authorization request requires additional information. Please submit your request on paper with complete clinical documentation." ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

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B.

STAT-PA RESPONSE Assigned PA Number First Date of Service Expiration Date Number of Days Approved Continued *Days' supply requested equals the total days allowed by prescription. For example, for a one-year supply, providers should enter "365." ____ ____ ____ ____ ____ ____ ____

STAT-PA DRUG WORKSHEET FOR BRAND NAME ACE INHIBITORS HCF 11057 (Rev. 08/03)

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ADDITIONAL INFORMATION The pharmacist learned of this diagnosis or reason for use when: The patient informed the pharmacist through patient consultation. In most cases, it is possible to learn the necessary information from the patient. The physician wrote the diagnosis or reason for use on this form or on a prior prescription order for this drug. The physician or personnel in the physician's office informed the pharmacist by telephone, either now or on a previous occasion.





Check the appropriate box: This is a new PA request. This is a renewed PA request.

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