F 11083 Form PDF Details

In today's healthcare landscape, the efficient management of prescription medications, especially when brand-name drugs are considered medically necessary over their generic counterparts, is a critical aspect of patient care and cost management. The F-11083 form, known as the FORWARDHEALTH PRIOR AUTHORIZATION / BRAND MEDICALLY NECESSARY ATTACHMENT (PA/BMNA), is a pivotal document in the State of Wisconsin's framework to address this very issue. Issued by the Department of Health Services, Division of Health Care Access and Accountability, this form acts as a conduit between prescribers and pharmacy providers, enabling a systematic approach to the prior authorization process. Critical sections of this form include member information, prescription details, clinical justifications for the brand-name prescription over a generic option, a thorough exploration of the patient’s medical history and reactions to medications, and specific criteria for drugs with a narrow therapeutic index. The form also mandates the detailed documentation of adverse reactions, treatment failures, or allergic responses encountered with the use of generic drugs, underscoring the importance of personalized patient care in prescribing practices. Such exhaustive detailing ensures that every prescription for a brand-name drug, marked as medically necessary, is backed by solid clinical evidence and reasoning, streamlining the prior authorization process while safeguarding patient health and optimizing therapeutic outcomes.

QuestionAnswer
Form NameF 11083 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesforward health drug prior authorization forms, forward health pa forms, forwardhealth prior authorization form, forward health prior authorization

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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-11083 (07/12)

DHS 152.06(3)(h), DHS 153.06(3)(g), DHS 154.06(3)(g), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / BRAND MEDICALLY NECESSARY ATTACHMENT (PA/BMNA)

INSTRUCTIONS: Type or print clearly. Before completing this form, read the Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA) Completion Instructions, F-11083A.

Prescribers are required to submit this completed form to the dispensing provider where the prescription will be filled.

Pharmacy providers may submit prior authorization (PA) requests with attachments to ForwardHealth by fax at (608) 221-8616 or by mail to ForwardHealth, Prior Authorization, Suite 88, 313 Blettner Boulevard, Madison, WI 53784.

SECTION I — MEMBER INFORMATION

1. Name — Member (Last, First, Middle Initial)

2. Date of Birth — Member

3. Member Identification Number

SECTION II — PRESCRIPTION INFORMATION

4. Drug Name

5. Strength(s)

6. National Drug Code (NDC)

7. Date Prescription Written

8. Directions for Use

9. Start Date Requested

10. Name — Prescriber

11. National Provider Identifier

12.Address — Prescriber (Street, City, State, ZIP+4 Code)

13.Telephone Number — Prescriber

14. Is “Brand Medically Necessary” handwritten by the prescriber on the prescription?

Yes

No

 

 

 

SECTION III — CLINICAL INFORMATION

15.Diagnosis — Primary Code and / or Description

16.Has the member experienced a clinically significant adverse reaction to the

generic equivalent drug?

Yes

No

If yes, indicate the adverse reaction that can be directly attributed to the generic equivalent drug and the dose and approximate dates the drug was taken.

17. Has the member experienced a treatment failure with the generic equivalent drug?

Yes

No

If yes, indicate the treatment failure that can be directly attributed to the generic equivalent drug and the dose and approximate dates the drug was taken.

Continued

PRIOR AUTHORIZATION / BRAND MEDICALLY NECESSARY ATTACHMENT (PA/BMNA)

 

 

 

Page 2 of 2

F-11083 (07/12)

 

 

 

 

 

 

 

 

 

SECTION III — CLINICAL INFORMATION (CONTINUED)

 

 

 

 

 

 

 

 

 

18. Has the member experienced an allergic reaction to the generic equivalent drug?

Yes

No

Do you anticipate that the brand name drug will not cause the same allergic reaction?

Yes

No

If yes, indicate the allergic reaction that can be directly attributed to the generic equivalent drug and the dose and approximate dates the drug was taken, if known.

19.Explain how the brand medically necessary drug will prevent the recurrence of the adverse reaction, treatment failure, or allergic reaction described in Elements 16, 17, and 18.

20.Does the member have a medical condition that causes a contraindication to the

use of the generic equivalent drug?

Yes

No

If yes, indicate the medical condition and why or how the condition impacts the use of the generic equivalent drug.

SECTION IIIB — CLINICAL INFORMATION FOR NARROW THERAPEUTIC INDEX DRUGS

21.For the Following Drugs Only: Any Brand Name Anticonvulsant Drug Used to Treat a Seizure Disorder, Clozaril, Coumadin, Neoral, or Prograf

Does the member’s past medical history suggest an anticipated treatment

 

 

failure of the generic equivalent drug?

Yes

No

If yes, indicate the prescriber’s documentation of the anticipated therapeutic failure* and the past medical history that forms the basis of the anticipated therapeutic failure.

*Therapeutic failure applies to treatment for seizure disorders.

22. SIGNATURE — Prescriber

23. Date Signed

SECTION IV — ADDITIONAL INFORMATION

24. Additional diagnostic and clinical information explaining the need for the drug required may be included below.