Medicine and Surgery Section - Wisconsin.gov
Medicine and Surgery Section - Wisconsin.gov
Medicine and Surgery Section - Wisconsin.gov
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
PRIOR AUTHORIZATION / “J” CODE ATTACHMENT (PA/JCA) Page 2 of 2<br />
HCF 11034 (Rev. 06/03)<br />
SECTION III — CLINICAL INFORMATION (Continued)<br />
16. Use (Check One)<br />
! Compendium st<strong>and</strong>ards, such as the USP-DI or drug package insert, list the intended use identified in Element 14 as<br />
an accepted or a [bracketed] indication.<br />
! The intended use identified in Element 14 is not listed in compendium st<strong>and</strong>ards. Peer reviewed clinical literature is<br />
attached.<br />
17. Dose (Check One)<br />
! The daily dose <strong>and</strong> duration are within compendium st<strong>and</strong>ards of general prescribing or dosing limits for the indicated<br />
use.<br />
! The daily dose <strong>and</strong> duration are not within compendium st<strong>and</strong>ards of general prescribing or dosing limits for the<br />
intended use. Attach peer-reviewed literature that indicates this dose is appropriate or document the medical necessity<br />
of this dosing difference.<br />
18. SIGNATURE — Prescriber 19. Date Signed<br />
Notify me of approval / denial by one of the following:<br />
! Fax — Fax Number — ___________________________________________________________________________<br />
! Telephone — Telephone Number — ________________________________________________________________<br />
! No special notice needed.