Prior Authorization/drug Attachment

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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), 152.06(3)(h), 153.06(3)(g), 154.06(3)(g)
F-11049 (07/2016)
FORWARDHEALTH
PRIOR AUTHORIZATION / DRUG ATTACHMENT (PA/DGA)
Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Drug Attachment (PA/DGA) Completion
Instructions, F-11049A. Providers may refer to the Forms page of the ForwardHealth Portal at
Content/provider/forms/index.htm.spage for the completion instructions.
Pharmacy providers are required to have a completed Prior Authorization/Drug Attachment (PA/DGA) form before 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)
3. Date of Birth – Member
2. Member Identification Number
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
SECTIONS IV-VIII
Complete the appropriate sections of this form:
•
Section IV for HealthCheck “Other Services” drug requests
•
Section V for diagnosis-restricted drug requests
•
Section VI for drugs with specific PA criteria addressed in the ForwardHealth Online Handbook
•
Section VII for other drug requests
•
Section VIII for additional information when extra space is needed to complete Sections IV–VII
Continued

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