DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 107.10(2), Wis. Admin. Code
F-11077 (12/12)
FORWARDHEALTH
PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL)
FOR NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS), INCLUDING
CYCLO-OXYGENASE INHIBITORS
Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Preferred Drug List (PA/PDL) for Non-
steroidal Anti-inflammatory Drugs (NSAIDs), Including Cyclo-oxygenase Inhibitors, Completion Instructions, F-11077A. 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 Non-steroidal Anti-
inflammatory Drugs (NSAIDs), Including Cyclo-oxygenase Inhibitors 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. 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 (Providers are required to complete Section III. For PA requests for cyclo-
oxygenase inhibitors, providers are also required to complete Section IIIA.)
12. Diagnosis Code and Description
13. Has the member experienced an unsatisfactory therapeutic response or experienced a clinically
significant adverse drug reaction with at least two preferred NSAIDs? (The two preferred NSAIDs
taken cannot include ibuprofen or naproxen.)
Yes
No
If yes, list the preferred NSAIDs and doses, specific details about the unsatisfactory therapeutic responses or clinically significant
adverse drug reactions, and the approximate dates the preferred NSAIDs were taken in the space provided.
1.
2.
3.
4.
Continued
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