RUG 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 R.
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How to fill out the WI DHS F-11075 online
Filling out the WI DHS F-11075 form, also known as the Prior Authorization/Preferred Drug List Exemption Request, is an important step for healthcare providers seeking necessary permissions for medications. This guide will provide you with comprehensive and clear instructions on how to complete this form online.
Follow the steps to fill out the WI DHS F-11075 form online.
- Press the ‘Get Form’ button to access the document and open it in your preferred online editing tool.
- Begin by filling out Section I, Member Information. Enter the member's name, identification number, and date of birth clearly to ensure accuracy.
- Proceed to Section II, Prescription Information. Input the drug name, strength, prescription writing date, directions for use, prescriber's name, their National Provider Identifier (NPI), address, and telephone number.
- Move on to Section III, Clinical Information. Fill out the diagnosis code and description. Indicate whether the member has experienced treatment failure with preferred drugs and provide the requested details if applicable.
- Continue by answering if the member has a medical condition that prevents the use of preferred drugs. List any relevant conditions as required.
- Answer whether there are clinically significant drug interactions or adverse drug reactions related to prescribed medications, providing details as necessary.
- Complete Section IV if you are a pharmacy provider using the STAT-PA system. This includes filling in the National Drug Code, days' supply requested, NPI, date of service, place of service, assigned PA number, grant date, expiration date, and the number of days approved.
- Finally, review all sections for accuracy and completeness. You can then save your changes, download, print, or share the completed form as required.
Begin filling out the WI DHS F-11075 form online today to ensure all necessary information is accurately submitted.
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