Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11303A (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 ELIDEL® AND PROTOPIC® COMPLETION INSTRUCTIONS
ForwardHealth requires certain information to authorize and pay for medical services provided to eligible members. Although these instructions refer to BadgerCare Plus, all information applies to Medicaid and SeniorCare. 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 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 items. 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. INSTRUCTIONS ® ® Prescribers are required to complete and sign the Prior Authorization/Preferred Drug List (PA/PDL) for Elidel and Protopic , F-11303. ® ® Pharmacy providers are required to use the PA/PDL for Elidel and Protopic to request PA using the Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) system or by submitting a paper PA request. Prescribers and pharmacy providers are required to retain a completed copy of the form. 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 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.

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR ELIDEL AND PROTOPIC COMPLETION INSTRUCTIONS F-11303A (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 and Telephone Number -- Prescriber Enter the complete address of the prescriber's practice location, including the street, city, state, and ZIP code, as well as the telephone number, including the area code, of the office, clinic, facility, or place of business of the prescriber.
® ® SECTION III -- CLINICAL INFORMATION FOR ELIDEL AND PROTOPIC Include diagnostic and clinical information explaining the need for the product requested. In Elements 11 through 16, check "yes" to all that apply.

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 description most relevant to the drug requested. The ICD-9-CM diagnosis code must correspond with the ICD-9-CM description and must be one of the approved diagnosis codes for Elidel® or Protopic®. Allowable diagnosis codes for Elidel® and Protopic® are 691.0 (diaper or napkin rash) or 691.8 (other atopic dermatitis and related conditions). Element 12 Check the appropriate box to indicate whether or not the prescription for Elidel® or Protopic® was written by a dermatologist or an allergist. Element 13 Check the appropriate box to indicate whether or not the member is over two years of age. Note: Elidel® Cream .1% is not indicated for use on children younger than two years of age. Protopic Ointment is not indicated for use on children younger than two years of age. Protopic 0.03% Ointment is indicated for use on children two to fifteen years of age. Element 14 Check the appropriate box to indicate whether or not the member is immunocompromised. Element 15 Check the appropriate box to indicate whether or not the member has taken an antiretroviral or antineoplastic agent within the past two years.

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR ELIDEL AND PROTOPIC COMPLETION INSTRUCTIONS F-11303A (10/08)

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Element 16 Check the appropriate box to indicate whether or not the member has experienced a treatment failure or a clinically significant adverse drug reaction with a topical corticosteroid in the past 183 days. If yes, indicate in the space provided the topical corticosteroid that the member experienced a treatment failure(s) on, the specific details about the treatment failure(s), and the approximate date(s) the topical corticosteroid was taken. Element 17 Check the appropriate box to indicate whether or not the member has received treatment with Elidel® or Protopic® in the last 183 days and achieved a measurable therapeutic response. 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 Elidel® and Protopic® 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 (NDC) for each drug. Element 21 -- Days' Supply Requested Enter the requested days' supply. Note: ForwardHealth will not approve a days' supply greater than 183 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. 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 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 STAT-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.