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STATE OF WISCONSIN DHS 107.06(2), Wis. Admin. Code DEPARTMENT OF HEALTH SERVICES Division of Medicaid Services F-11034 (07/2012) DHS 152.06(3)(h), 153.06(3)(g), 154.06(3)(g), Wis. Admin. Code FORWARDHEALTH PRIOR AUTHORIZATION / “J” CODE ATTACHMENT (PA/JCA) Providers may submit prior authorization (PA) requests with attachments to ForwardHealth by fax at 608-221-8616 or by mail to ForwardHealth, Prior Authorization, Suite 88, 313 Blettner Boulevard, Madison, WI 53784. Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/"J" Code Attachment (PA/JCA) Completion Instructions, F-11034A. SECTION I — MEMBER INFORMATION 1. Name — Member (Last, First, Middle Initial) 2. Date of Birth — Member 3. Member Identification Number SECTION II — DRUG ORDER INFORMATION 4. Drug Name 5. Strength 6. National Drug Code 7. HCPCS “J” Code 8. Quantity Ordered 9. Date Order Issued 10. Daily Dose 11. Name — Prescriber 12. National Provider Identifier 13. “Brand Medically Necessary” Yes No If yes, please indicate and describe the adverse reaction, allergic reaction, or actual therapeutic failure in the space provided. SECTION III — CLINICAL INFORMATION 14. Diagnosis 15. Changes to Previous Clinical Condition Continued

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Page 1: PRIOR AUTHORIZATION / “J” CODE ATTACHMENT (PA/JCA), · prior authorization / “j” code attachment (pa/jca) Providers may submit prior authorization (PA) requests with attachments

STATE OF WISCONSIN DHS 107.06(2), Wis. Admin. Code

DEPARTMENT OF HEALTH SERVICES Division of Medicaid ServicesF-11034 (07/2012) DHS 152.06(3)(h), 153.06(3)(g), 154.06(3)(g), Wis. Admin. Code

FORWARDHEALTH PRIOR AUTHORIZATION / “J” CODE ATTACHMENT (PA/JCA)

Providers may submit prior authorization (PA) requests with attachments to ForwardHealth by fax at 608-221-8616 or by mail to ForwardHealth, Prior Authorization, Suite 88, 313 Blettner Boulevard, Madison, WI 53784. Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/"J" Code Attachment (PA/JCA) Completion Instructions, F-11034A.

SECTION I — MEMBER INFORMATION 1. Name — Member (Last, First, Middle Initial) 2. Date of Birth — Member

3. Member Identification Number

SECTION II — DRUG ORDER INFORMATION 4. Drug Name 5. Strength

6. National Drug Code 7. HCPCS “J” Code

8. Quantity Ordered 9. Date Order Issued 10. Daily Dose

11. Name — Prescriber

12. National Provider Identifier 13. “Brand Medically Necessary”

Yes NoIf yes, please indicate and describe the adverse reaction, allergic reaction, or actual therapeutic failure in the space provided.

SECTION III — CLINICAL INFORMATION 14. Diagnosis

15. Changes to Previous Clinical Condition

Continued

Page 2: PRIOR AUTHORIZATION / “J” CODE ATTACHMENT (PA/JCA), · prior authorization / “j” code attachment (pa/jca) Providers may submit prior authorization (PA) requests with attachments

Page 2 of 2 PRIOR AUTHORIZATION / “J” CODE ATTACHMENT (PA/JCA) F-11034 (07/2012)

SECTION III — CLINICAL INFORMATION (Continued) 16. Use (Check One)

Compendium standards, such as the United States Pharmacopeia Dispensing Information (USP-DI) or drug package insert,lists the intended use previously identified as an accepted or a [bracketed] indication.

The intended use identified above is not listed in compendium standards. Peer-reviewed clinical literature is attached.

17. Dose (Check One)

The daily dose and duration are within compendium standards of general prescribing or dosing limits for the indicated use. The daily dose and duration are not within compendium standards of general prescribing or dosing limits for the intended

use. Attach peer-reviewed literature that indicates this dose is appropriate or document the medical necessity of this dosingdifference.

18. SIGNATURE — Prescriber 19. Date Signed


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