F-00194 - Forwardhealth Prior Authorization/preferred Drug List (Pa/pdl) For Antiemetics, Cannabinoids Page 3

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PRIOR AUTHORIZATION PREFERRED DRUG LIST (PA/PDL) FOR ANTIEMETICS, CANNABINOIDS

F-00194 (11/09)

SECTION IV — FOR PHARMACY PROVIDERS USING STAT-PA

23. National Drug Code (11 Digits)

24. Days’ Supply Requested (Up to 183 Days)

25. NPI

26. Date of Service (MM/DD/CCYY) (For STAT-PA requests, the date of service may be up to 31 days in the future and / or up to 14

days in the past.)

27. Patient Location (Use patient location code “0” [Not specified], “1” [Home], “4” [Long Term / Extended Care], “7” [Skilled Care

Facility], or “10” [Outpatient].)

28. Assigned PA Number

29. Grant Date

30. Expiration Date

31. Number of Days Approved

SECTION V — AUTHORIZED SIGNATURE

32. SIGNATURE — Prescriber

33. Date Signed

SECTION VI — ADDITIONAL INFORMATION

34. Include any additional information in the space below. Additional diagnostic and clinical information explaining the need for the

product requested may be included here.

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Parent category: Medical