Prior Authorization / Brand Medically Necessary Attachment
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1
2DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 107.10(2), Wis. Admin. Code
F-11083 (01/15)
FORWARDHEALTH
PRIOR AUTHORIZATION / BRAND MEDICALLY NECESSARY ATTACHMENT (PA/BMNA)
Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Brand Medically Necessary Attachment
(PA/BMNA) Completion Instructions, F-11083A. 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/Brand Medically Necessary Attachment (PA/BMNA) form
signed by the prescriber before submitting a prior authorization (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 — Prescriber
10. Address — Prescriber (Street, City, State, ZIP+4 Code)
11. Telephone Number — Prescriber
SECTION III — CLINICAL INFORMATION
12. Diagnosis — Primary Code and / or Description
As required in DHS 107.10(3)(c), Wis. Admin. Code, when a prescription is for a BMN drug, the prescriber is required to write "brand
medically necessary" in his or her own handwriting. This required statement may be handwritten either directly on the prescription or on
a separate order attached to the original prescription. Typed certification, signature stamps, or certification handwritten by someone
other than the prescriber does not satisfy this requirement. Blanket authorization for an individual member, drug, or prescriber is not
acceptable documentation.
13. Is “brand medically necessary” handwritten by the prescriber on the prescription or on a
separate order attached to the original prescription?
Yes
No
14. Is the brand medically necessary request for one of the following drugs?
Yes
No
•
Anticonvulsant used to treat a seizure disorder.
•
Cellcept.
•
Coumadin.
•
Neoral.
•
Prograf.
If yes, skip Elements 15-17 and proceed to Elements 18-19.
Continued
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