Instructions for Form F-00142 Prior Authorization Drug Attachment for Synagis - Wisconsin

Form F-00142 Prior Authorization Drug Attachment for Synagis - Wisconsin

This document contains official instructions for Form F-00142 , Prior Authorization Drug Attachment for Synagis - a form released and collected by the Wisconsin Department of Health Services. An up-to-date fillable Form F-00142 is available for download through this link.

FAQ

Q: What is Form F-00142?
A: Form F-00142 is the Prior Authorization Drug Attachment for Synagis in Wisconsin.

Q: What is Synagis?
A: Synagis is a medication used to prevent serious lung infections in infants at high risk.

Q: Why do I need to fill out Form F-00142?
A: Form F-00142 is required to request prior authorization for Synagis treatment.

Q: What information do I need to provide on Form F-00142?
A: You will need to provide your personal information, the infant's information, healthcare provider's information, and clinical justification for the Synagis treatment.

Q: Who is eligible for Synagis treatment?
A: Infants at high risk for serious lung infections, such as premature infants or infants with certain medical conditions, may be eligible for Synagis treatment.

Q: How long does the prior authorization process take?
A: The length of the prior authorization process can vary, but it is important to submit the form well in advance of the anticipated Synagis treatment start date.

Q: Can I appeal if my prior authorization request is denied?
A: Yes, if your prior authorization request is denied, you have the right to appeal the decision.