F-00194 - Forwardhealth Prior Authorization/preferred Drug List (Pa/pdl) For Antiemetics, Cannabinoids

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 107.10(2), 152.06(3)(h), Wis. Admin. Code
F-00194 (11/09)
DHS 153.06(3)(g), 154.06(3)(g), Wis. Admin. Code
FORWARDHEALTH
PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL)
FOR ANTIEMETICS, CANNABINOIDS
Instructions: Print or type clearly. Refer to the Prior Authorization/Preferred Drug List (PA/PDL) for Antiemetics, Cannabinoids
Completion Instructions, F-00194A, for more information.
Pharmacy providers are required to have a completed PA/PDL for Antiemetics, Cannabinoids signed by the prescriber before calling
Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) or submitting a paper prior authorization (PA) request.
Providers may call ForwardHealth 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,
Section III A or Section III B, and Section VI of this form and submit the request to ForwardHealth on the ForwardHealth
Portal or on paper by mail or fax. Prior authorization requests for dronabinol must include clinical justification for
®
prescribing dronabinol instead of Marinol
. Additional documentation should be included in Section VI or submitted as an
attachment.)
12. Diagnosis Code and Description
®
SECTION III A — CLINICAL INFORMATION FOR MARINOL
ONLY
13. Has the member been diagnosed with a loss of appetite / weight loss caused by
Human Immunodeficiency Virus or Acquired Immune Deficiency Syndrome?
 Yes
 No
®
SECTION III B — CLINICAL INFORMATION FOR MARINOL
AND CESAMET
14. Has the member experienced a treatment failure with ondansetron for
chemotherapy-related nausea and vomiting?
 Yes
 No
15. Does the member have a medical condition(s) preventing the use of ondansetron?
 Yes
 No
If yes, list the medical condition(s) that prevents the use of ondansetron in the space provided.
Continued

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