Prior Authorization For Stimulants And Related Drugs

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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-11097 (12/12)
FORWARDHEALTH
PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL)
FOR STIMULANTS AND RELATED AGENTS
Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Preferred Drug List (PA/PDL) for
Stimulants and Related Agents Completion Instructions, F-11097A. 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 Stimulants and Related
Agents 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 FOR STIMULANTS AND RELATED AGENTS (Providers are required to complete
Section III and either Section IIIA or Section IIIB.)
12. Diagnosis Code and Description
SECTION IIIA — CLINICAL INFORMATION FOR NON-PREFERRED STIMULANTS REQUESTS (Excluding Kapvay.)
13. Has the member experienced an unsatisfactory therapeutic response or experienced a clinically
significant adverse drug reaction with at least two preferred stimulants?
Yes
No
If yes, list the preferred stimulants and doses, specific details about the unsatisfactory therapeutic responses or clinically
significant adverse drug reactions, and the approximate dates the preferred stimulants were taken in the space provided.
1.
2.
3.
4.
Continued

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