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Get WI DHS F-11075 2013-2024

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 me.

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