Prior Authorization Templates

This Form is used for individuals seeking prior authorization for adult mental health day treatment in Wisconsin.

This document provides instructions for completing Form F-00556, which is used for obtaining prior authorization for antipsychotic drugs for children 8 years of age and younger in Wisconsin.

This form is used for obtaining prior authorization and submitting a substance abuse attachment in the state of Wisconsin.

This Form is used for requesting amendments to a prior authorization in Wisconsin.

This Form is used for submitting a Prior Authorization Request in Wisconsin. It allows individuals to request approval for specific medical procedures or medications that may require additional review and approval from the healthcare insurance provider.

This form is used for obtaining prior authorization or preferred drug list for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets in Wisconsin.

This Form is used for prior authorization of cytokine and cell adhesion molecule (CAM) antagonist drugs for various conditions including Deficiency of Interleukin-1 Receptor Antagonist (DIRA), Giant Cell Arteritis, Neonatal Onset Multisystem Inflammatory Disease (NOMID), and Non-radiographic Axial Spondyloarthritis (nr-axSpA) in Wisconsin.

This Form is used for prior authorization of Cytokine and Cell Adhesion Molecule (CAM) antagonist drugs for specific medical conditions in Wisconsin.

This Form is used for prior authorization and preferred drug list for non-preferred stimulants in Wisconsin. It provides instructions on how to request approval for medication coverage.

This Form is used for prior authorization and preferred drug list for non-injectable headache agents (Triptans) in Wisconsin.

This Form is used for providing instructions on how to complete Form F-01629 Prior Authorization/Behavioral Treatment Attachment (PA/BTA) in the state of Wisconsin. It is important to follow these instructions carefully in order to ensure proper submission of the form.

This form is used for acknowledging the prior authorization of private duty nursing services in the state of Wisconsin.

This form is used for obtaining prior authorization for cytokine and cell adhesion molecule (CAM) antagonist drugs in Wisconsin for the treatment of Crohn's disease and ulcerative colitis.

This form is used for prior authorization and requires a physician attachment. It is specific to Wisconsin.

This form is used for submitting a prior authorization request for intensive in-home treatment in Wisconsin.

This Form is used for obtaining prior authorization and preferred drug list for Non-steroidal anti-inflammatory drugs (NSAIDs) in Wisconsin.

This form is used for obtaining prior authorization or preferred drug list (Pa/Pdl) for non-steroidal anti-inflammatory drugs (NSAIDs) in the state of Wisconsin.

This Form is used for submitting a prior authorization drug attachment for non-preferred stimulants and related wake-promoting agents in Wisconsin's ForwardHealth program. It provides instructions on how to complete the form and submit it for approval.

This form is used for providing prior authorization and therapy attachment in the state of Wisconsin.

This form is used for requesting prior authorization for hypoglycemic medications known as Glucagon-like Peptide (GLP-1) agents in the state of Wisconsin.

This form is used for submitting a prior authorization request for a speech-generating device in the state of Wisconsin.

This form is used for requesting prior authorization for oral surgery, orthodontic, and fixed prosthetic services in Wisconsin.

This document provides instructions for completing Form F-02433, which is used for requesting prior authorization or preferred drug list status for the medication Epidiolex in the state of Wisconsin. It outlines the process and requirements for obtaining coverage for this specific drug.

This Form is used for submitting a prior authorization drug attachment for the medication Synagis in the state of Wisconsin.

This form is used for prior authorization of a prolonged hospital stay in Wisconsin. It is used as a fax cover sheet for submitting the required documents.

This Form is used for prior authorization of intensive in-home mental health/substance abuse services assessment and recovery/treatment plan attachment in the state of Wisconsin. It provides instructions for completing the form.

This Form is used for submitting a prior authorization request for intensive in-home mental health and substance abuse services in Wisconsin. It includes an assessment and recovery/treatment plan attachment.

This Form is used for requesting prior authorization for speech-generating devices in Wisconsin. It is an attachment that provides information about the skills and needs of the individual in need of the device.

This form is used for prior authorization and preferred drug list for growth hormone drugs in Wisconsin.

This form is used for obtaining prior authorization for cytokine and cell adhesion molecule (CAM) antagonist drugs used to treat psoriasis in the state of Wisconsin.

This type of document provides instructions for filling out Form F-11306, which is a prior authorization drug attachment specific to cytokine and cell adhesion molecule (CAM) antagonist drugs for treating psoriasis in the state of Wisconsin.

This medical form is specifically for use in Vermont for requesting prior authorization for certain medical procedures or treatments.

This form is used for requesting prior authorization for a brand name medication in Vermont.