Prior Authorization / Preferred Drug List

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 107.10(2), Wis. Admin. Code
F-11075 (09/13)
FORWARDHEALTH
PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) EXEMPTION REQUEST
Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Preferred Drug List (PA/PDL) Exemption
Request Completion Instructions, F-11075A. 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) Exemption Request 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, 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 (NPI) — Prescriber
10. Address — Prescriber (Street, City, State, ZIP+4 Code)
11. Telephone Number — Prescriber
SECTION III — CLINICAL INFORMATION (Required for all PA requests.)
12. Diagnosis Code and Description
13. List the PDL drug class to which the requested non-preferred drug belongs (e.g., COPD agents).
Note: If applicable, prescribers may also complete Section IV of this form if the non-preferred drug belongs to one of the following drug classes:
Alzheimer’s Agents; Anticonvulsants; Antidepressants, Other; Antidepressants, SSRI; Antiparkinson’s Agents; Antipsychotics; HIV-AIDS; or
Pulmonary Arterial Hypertension.
14. Has the member experienced an unsatisfactory therapeutic response or a clinically
significant adverse drug reaction with at least one of the preferred drugs from the same
PDL drug class as the drug being requested?
Yes
No
If yes, list the preferred drug(s) used.
List the dates the preferred drug(s) was taken.
Describe the unsatisfactory therapeutic response(s) or clinically significant adverse drug reaction(s).
Continued

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