Form F-00080 - Prior Authorization / Preferred Drug List (Pa/pdl) For Symlin

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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-00080 (10/11)
FORWARDHEALTH
PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR SYMLIN
Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Preferred Drug List (PA/PDL) for Symlin
Completion Instructions, F-00080A. 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 Symlin 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. Refills
8. Directions for Use
9. Name — Prescriber
10. National Provider Identifier — Prescriber
11. Address — Prescriber (Street, City, State, ZIP+4 Code)
12. Telephone Number — Prescriber
SECTION III — CLINICAL INFORMATION
13. Diagnosis Code and Description
14. State the member’s most current HbA1c.
15. Date Member’s HbA1c Measured
%
 Yes
 No
16. Is the member using Symlin for weight loss?
 Yes
 No
17. Is the member currently receiving insulin injections?
 Yes
 No
18. Is the member currently receiving meal-time insulin injections?
 Yes
 No
19. Is the member 18 years of age or older?
 Yes
 No
20. Does the member currently have or have a history of gastroparesis?
 Yes
 No
21. Does the member currently have or have a history of hypoglycemia unawareness?
22. Has the member required emergency treatment for severe hypoglycemia in the past
 Yes
 No
six months?
If yes, how many times?
Zero
One
Two
Three or greater
Continued

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