Form F-11092 - Prior Authorization / Preferred Drug List (Pa/pdl) For Growth Hormone Drugs

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 107.10(2), Wis. Admin. Code
F-11092 (10/13)
FORWARDHEALTH
PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL)
FOR GROWTH HORMONE DRUGS
Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Preferred Drug List (PA/PDL) for Growth
Hormone Drugs Completion Instructions, F-11092A. Providers may refer to the Forms page of the ForwardHealth Portal at
for the completion instructions.
Pharmacy providers are required to have a completed Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs
form signed by the prescriber before calling the Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) system
or submitting a PA request on the Portal or on paper. Providers may call Provider Services at (800) 947-9627 with questions.
SECTION I — MEMBER INFORMATION
1. Name — Member (Last, First, Middle Initial)
2. Member Identification Number
3. Date of Birth — Member
SECTION II — PRESCRIPTION INFORMATION
4. Drug Name
5. Drug Strength
6. Date Prescription Written
7. Refills
8. Directions for Use
9. Name — Prescriber
10. National Provider Identifier (NPI) — Prescriber
11. Address — Prescriber (Street, City, State, ZIP+4 Code)
12. Telephone Number — Prescriber
SECTION III — CLINICAL INFORMATION
13. Diagnosis Code and Description
Complete the appropriate section of this form:
PA requests for growth hormone drugs (except Serostim or Zorbtive): complete Section IIIA only.
PA requests for Serostim: complete Section IIIB only.
PA requests for Zorbtive: Complete Section IIIC only.
SECTION IIIA — CLINICAL INFORMATION FOR GROWTH HORMONE DRUGS (EXCEPT SEROSTIM OR ZORBTIVE)
14. Is the drug requested a preferred growth hormone drug?
Yes
No
If the drug is a non-preferred growth hormone drug, describe the reason for the request in the space provided.
15. Is the member 17 years of age or younger?
Yes
No
Continued

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