Form F 11075 PDF Details

Navigating the intricacies of healthcare documentation and processes requires a keen understanding of specific forms and their purposes, particularly when it involves medication and treatment authorization. Among these, the F-11075 form stands out as a critical document within the Wisconsin Department of Health Services, specifically under the Division of Health Care Access and Accountability. This form facilitates a Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request, a process essential for healthcare providers who need to prescribe medications not readily available on the Preferred Drug List without going through standard authorization channels. The detailed instructions guide providers on how to complete the request accurately, emphasizing the importance of clarity and precision in providing member information, prescription details, clinical justifications, and potential eligibility for alternate clinical pathways for certain drug classes. The form also accommodates detailed clinical information, including diagnosis codes, therapeutic responses, and drug interactions, ensuring that the patient's needs are thoroughly evaluated and met. This rigorous documentation process underscores the form's role in facilitating access to necessary medications, thereby highlighting the interconnectedness of healthcare provision, regulatory requirements, and patient well-being.

QuestionAnswer
Form NameForm F 11075
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other nameswi medicaid prior authorization forms, papdl wisconsin form, prior authorization wisconsin online, form papdl

Form Preview Example

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 www.forwardhealth.wi.gov/WIPortal/Content/provider/forms/index.htm.spage 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

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) EXEMPTION REQUEST

Page 2 of 3

F-11075 (09/13)

 

SECTION III — CLINICAL INFORMATION (Required for all PA requests.) (Continued)

15.Is there a clinically significant drug interaction between another drug the member is taking and at least one of the preferred drugs from the same PDL drug class as the drug

being requested?

Yes

No

If yes, list the drug(s) and interaction(s) in the space provided.

16. Does the member have a medical condition(s) that prevents the use of at least one of the

 

 

preferred drugs from the same PDL drug class as the drug being requested?

Yes

No

If yes, list the medical condition(s) and describe how the condition(s) prevents the member from using the preferred drug(s) in the space provided.

SECTION IV — ALTERNATE CLINICAL INFORMATION FOR ELIGIBLE DRUG CLASSES ONLY (If applicable, prescribers may also complete this section.)

17. Indicate the drug class.

 

 

Alzheimer’s Agents

Antiparkinson’s Agents

Anticonvulsants

Antipsychotics

Antidepressants, Other

HIV-AIDS

Antidepressants, SSRI

Pulmonary Arterial Hypertension

18.

Is the member new to ForwardHealth (i.e., has this member been granted eligibility for

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ForwardHealth within the past month)?

Yes

 

 

No

 

 

 

 

If yes, indicate the month and year the member became eligible in the space provided.

 

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

 

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19.

Has the member taken the requested non-preferred drug continuously for the last 30

 

 

 

 

 

 

 

 

 

 

 

 

 

 

days or longer and had a measurable therapeutic response?

Yes

 

 

 

No

 

 

 

 

If yes, indicate the month and year the member began taking the drug in the space provided.

 

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

 

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20. Was the member recently discharged from an inpatient stay in which the member was

 

 

 

 

 

 

 

 

 

 

 

 

 

 

stabilized on the non-preferred drug being requested?

Yes

 

 

 

No

 

 

 

 

If yes, indicate the facility and month and year of discharge in the space provided.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Facility Name

 

 

 

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

 

 

 

Year

 

 

 

21. SIGNATURE — Prescriber

22. Date Signed

Continued

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) EXEMPTION REQUEST

Page 3 of 3

F-11075 (09/13)

 

SECTION V — FOR PHARMACY PROVIDERS USING STAT-PA

23. National Drug Code (11 Digits)

24. Days’ Supply Requested (Up to 365 Days)

25.NPI

26.Date of Service (MM/DD/CCYY) (For STAT-PA requests, the date of service may be up to 31 days in the future and / or up to 14 days in the past.)

27.Place of Service

28.Assigned PA Number

29. Grant Date

30. Expiration Date

31. Number of Days Approved

SECTION VI — ADDITIONAL INFORMATION

32.Include any additional information in the space below. Additional diagnostic and clinical information explaining the need for the drug requested may be included here.

How to Edit Form F 11075 Online for Free

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This PDF form requires some specific information; in order to ensure accuracy and reliability, make sure you bear in mind the tips just below:

1. The prior authorization wisconsin online usually requires certain details to be typed in. Ensure the next fields are finalized:

Tips to prepare wisconsin prior authorization portion 1

2. Once the previous part is complete, it's time to include the required specifics in Has the member experienced an, significant adverse drug reaction, Yes, If yes list the preferred drugs, List the dates the preferred drugs, Describe the unsatisfactory, and Continued so that you can move on further.

How one can fill in wisconsin prior authorization portion 2

Be really mindful when completing Has the member experienced an and Yes, as this is where a lot of people make mistakes.

3. This next stage will be hassle-free - complete all the fields in Is there a clinically significant, taking and at least one of the, If yes list the drugs and, Yes, Does the member have a medical, preferred drugs from the same PDL, Yes, If yes list the medical conditions, SECTION IV ALTERNATE CLINICAL, Indicate the drug class, and Antiparkinsons Agents in order to complete this part.

wisconsin prior authorization completion process clarified (step 3)

4. The form's fourth subsection comes next with the next few blanks to fill out: Indicate the drug class, Antiparkinsons Agents, Is the member new to, ForwardHealth within the past month, Yes, If yes indicate the month and year, Month, Year, Has the member taken the, days or longer and had a, Yes, If yes indicate the month and year, Month, Year, and Was the member recently.

Antiparkinsons Agents, Yes, and Year inside wisconsin prior authorization

5. As you approach the end of this form, there are actually a few extra requirements that have to be met. Mainly, SECTION V FOR PHARMACY PROVIDERS, National Drug Code Digits, Days Supply Requested Up to Days, NPI, Date of Service MMDDCCYY For, days in the past, Place of Service, Assigned PA Number, Grant Date, Expiration Date, Number of Days Approved, SECTION VI ADDITIONAL INFORMATION, Include any additional, and drug requested may be included here must all be filled out.

Part number 5 for filling in wisconsin prior authorization

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