Prior Authorization Templates

This form is used for prior authorization of home health therapy services in Wisconsin.

This Form is used for requesting prior authorization for behavioral treatment in Wisconsin.

This Form is used for obtaining prior authorization and checking the preferred drug list for stimulants and related agents in the state of Wisconsin.

This form is used for attaching prior authorization for headache agents in Wisconsin for acute treatment.

This type of document is used in Wisconsin for submitting a Prior Authorization/Mental Health and/or Substance Abuse Evaluation Attachment.

This Form is used for obtaining prior authorization for long-acting hypoglycemic medications in Wisconsin.

This form is used for submitting a prior authorization request for long-acting insulin medications in the state of Wisconsin. It is an attachment specifically for hypoglycemic medications. The form provides instructions on how to complete the necessary information for the prior authorization request.

This form is used for attaching prior authorization drug information for Wakix in the state of Wisconsin. It provides instructions for completing the form.

This form is used for attaching a prior authorization drug request for Wakix medication in the state of Wisconsin.

This Form is used for providing instructions on how to fill out Form F-02493 for Prior Authorization of a Speech-Generating Device Purchase in Wisconsin.

This Form is used for providing prior authorization and assessing the skills and needs of individuals who require speech-generating devices in the state of Wisconsin.

This document is a form used in Wisconsin for obtaining prior authorization for substance abuse day treatment.

This form is used for obtaining prior authorization and submitting a physician's report for otological services in the state of Wisconsin.

This document is used for obtaining prior authorization for health and behavior interventions in Wisconsin.

This Form is used for obtaining prior authorization for child/adolescent day treatment services in Wisconsin.

This form is used for obtaining prior authorization or adding Epidiolex to the preferred drug list (Pa/Pdl) in the state of Wisconsin. It is required for coverage of this medication.

This Form is used for providing prior authorization for the drugs Xyrem and Xywav in the state of Wisconsin. It serves as an attachment to Form F-01430.

This document is used for submitting a prior authorization request for the drugs Xyrem and Xywav in the state of Wisconsin.

This Form is used for submitting a prior authorization request for Multiple Sclerosis (MS) drugs in Wisconsin. It is important to fill out this form correctly and provide all necessary information to ensure approval for MS medication.

This form is used for requesting prior authorization for multiple sclerosis drugs in Wisconsin.

This form is used for obtaining prior authorization for non-preferred stimulants and related agents used for wake-promoting purposes in Wisconsin.

This Form is used for submitting a Prior Authorization/Enteral Nutrition Formula Attachment (Pa/Enfa) in the state of Wisconsin. It provides instructions on how to complete the form and required documentation.

This form is used for submitting a prior authorization request for enteral nutrition formulas in the state of Wisconsin.

This Form is used for submitting a prior authorization drug attachment for antiemetics and cannabinoids in the state of Wisconsin. It provides instructions on how to complete and submit the form for approval.

This form is used for attaching prior authorization information for antiemetic and cannabinoid drugs in Wisconsin.

This Form is used for obtaining prior authorization for chiropractic services in the state of Wisconsin.

This form is used for obtaining prior authorization for residential substance use disorder treatment in Wisconsin.

This document is a Prior Authorization Drug Attachment form specific to the state of Wisconsin. It is used for requesting approval for antipsychotic drugs for children who are 8 years of age and younger.

This Form is used for requesting prior authorization and accessing the preferred drug list for non-injectable headache agents called Triptans in Wisconsin. It provides instructions on how to complete the form and what is required for approval.

This form is used for prior authorization/preferred drug list for non-preferred stimulants in Wisconsin.

This form is used for submitting a prior authorization request for "j" code attachment in Wisconsin.

This Form is used for requesting prior authorization or preferred drug list coverage for growth hormone drugs in Wisconsin. It provides instructions on how to complete the form correctly.

This document is used for submitting a prior authorization request for brand name medications that are deemed medically necessary in the state of Wisconsin.

This Form is used for requesting prior authorization for brand medically necessary attachments in Wisconsin. It is required to ensure coverage for specific medications deemed medically necessary.

This form is used for submitting prior authorization for headache agents used in preventative treatment in the state of Wisconsin.

This form is used for requesting prior authorization for lipotropics and omega-3 acids drugs in the state of Wisconsin.

This form is used for obtaining prior authorization for oxygen equipment in the state of Wisconsin.