Form F-11078 - Prior Authorization / Preferred Drug List (Pa/pdl) For Proton Pump Inhibitor (Ppi) Capsules And Tablets

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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)
F-11078 (07/15)
FORWARDHEALTH
PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL)
FOR PROTON PUMP INHIBITOR (PPI) CAPSULES AND TABLETS
Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Preferred Drug List (PA/PDL) for Proton
Pump Inhibitor (PPI) Capsules and Tablets Completion Instructions, F-11078A. 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 Proton Pump Inhibitor (PPI)
Capsules and Tablets 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 (NPI) — Prescriber
11. Address — Prescriber (Street, City, State, ZIP+4 Code)
12. Telephone Number — Prescriber
SECTION III — CLINICAL INFORMATION (Required for all PA requests.)
13. Diagnosis Code and Description
Continued

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