DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
Wis. Admin. Code § DHS 107.10(2)
PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR CYTOKINE AND CELL
ADHESION MOLECULE (CAM) ANTAGONIST DRUGS FOR ANKYLOSING SPONDYLITIS
Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine
and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis Completion Instructions, F-11304A. Providers may
refer to the Forms page of the ForwardHealth Portal at
the completion instructions.
Pharmacy providers are required to have a completed Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion
Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis 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. 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 ANKYLOSING SPONDYLITIS
12. Diagnosis Code and Description
13. Does the member have ankylosing spondylitis?
14. Is the prescription written by a rheumatologist or through a rheumatology consultation?
15. Does the member have axial symptoms of ankylosing spondylitis?