Pharmacy Special Handling Request
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1
2
3DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
Wis. Admin. Code § DHS 107.10(2)
F-00081 (07/2016)
FORWARDHEALTH
PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL)
FOR OPIOID DEPENDENCY AGENTS – BUPRENORPHINE
Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Preferred Drug List (PA/PDL) for Opioid
Dependency Agents – Buprenorphine Completion Instructions, F-00081A. 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 Opioid Dependency Agents
– Buprenorphine 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)
3. Date of Birth – Member
2. Member Identification Number
SECTION II – PRESCRIPTION INFORMATION
5. Drug Strength [Check Strength(s)]
4. Drug Name (Check One)
®
®
Suboxone
Film
Suboxone
Film
2 mg
4 mg
8 mg
12 mg
Other
Other
1.4 mg
2 mg
5.7 mg
8 mg
Or
mg
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
14. Is the member 16 years of age or older?
Yes
No
15. Does the prescriber have a valid Drug Addiction Treatment Act (DATA 2000) waiver
allowing him or her to prescribe buprenorphine-based agents for opioid dependency treatment?
Yes
No
If yes, enter the prescriber’s “X” Drug Enforcement Administration (DEA) number in the space provided.
16. Has the prescriber read the educational brochure titled “Office-Based Buprenorphine Therapy for
Opioid Dependence: Important Information for Prescribers” provided through the Buprenorphine-
containing Transmucosal products for Opioid Dependence (BTOD) Risk Evaluation and
Mitigations Strategy (REMS) program?
Yes
No
If yes, has the prescriber communicated the key messages to the member about the risks
of accidental overdose, misuse, and abuse while taking products covered under the BTOD
REMS program?
Yes
No
Continued
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