Prior Authorization / Preferred Drug List

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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-00194 (07/13)
FORWARDHEALTH
PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL)
FOR ANTIEMETICS, CANNABINOIDS
Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Preferred Drug List (PA/PDL) for
Antiemetics, Cannabinoids Completion Instructions, F-00194A. 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 Antiemetics, Cannabinoids
form signed by the prescriber before submitting a PA request on the Portal, by fax, or by mail. 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. Directions for Use
8. Name — Prescriber
9. National Provider Identifier (NPI) — Prescriber
10. Address — Prescriber (Street, City, State, ZIP+4 Code)
11. Telephone Number — Prescriber
SECTION III — CLINICAL INFORMATION (For PA requests for dronabinol, providers are required to complete Section III and
either Section III A or Sections III B and III C of this form.)
12. Diagnosis Code and Description
®
SECTION III A — CLINICAL INFORMATION FOR MARINOL
FOR HIV- AND AIDS-RELATED WEIGHT LOSS OR CACHEXIA
13. Is the member experiencing weight loss or cachexia caused by Human
Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS)?
Yes
No
14. Current Height — Member (In Inches)
15. Current Weight — Member (In Pounds)
Weight ___________________(lbs)
Date Taken ____ ____ / ____ ____ / ____ ____ ____ ____
Month
Day
Year
2
16. Body Mass Index (BMI) — Member (lb/in
)
BMI = 703 X (Weight in Pounds)
2
(Height in Inches)
17. List the details about the actions used to increase the member’s dietary intake.
Continued

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