Form F-11035 - Prior Authorization/preferred Drug List (Pa/pdl) For Cytokine

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
Wis. Admin. Code § DHS 107.10(2)
F-11305 (01/2016)
FORWARDHEALTH
PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR CYTOKINE AND CELL
ADHESION MOLECULE (CAM) ANTAGONIST DRUGS FOR CROHN’S DISEASE
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 Crohn’s Disease Completion Instructions, F-11305A. 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 Cytokine and Cell Adhesion
Molecule (CAM) Antagonist Drugs for Crohn’s Disease 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, 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 CROHN’S DISEASE
12. Diagnosis Code and Description
13. Does the member have a diagnosis of Crohn’s disease?
Yes
No
14. Does the member have moderate to severe symptoms of Crohn’s disease?
Yes
No
15. Is the prescription written by a gastroenterologist or through a gastroenterology consultation?
Yes
No
Continued

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