Get Wi Dhs F-11075 2013-2025

The WI DHS F-11075 form, used for Prior Authorization/Preferred Drug List Exemption Requests, is essential for securing necessary medications for individuals under ForwardHealth. This guide will provide you with step-by-step instructions on how to accurately fill out this form online.

Follow the steps to successfully complete the WI DHS F-11075 form online.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin with Section I — Member Information. Accurately fill in the name of the member (last, first, middle initial) and their identification number. Also include the member's date of birth.
3. Proceed to Section II — Prescription Information. In this section, provide details such as the drug name, drug strength, date of prescription written, directions for use, name of the prescriber, their National Provider Identifier (NPI), address, and telephone number.
4. Move to Section III — Clinical Information. Complete the required diagnosis code and description, and indicate the PDL drug class to which the requested non-preferred drug belongs. Answer the questions regarding therapeutic responses, drug interactions, and medical conditions that may impact drug usage.
5. If applicable, complete Section IV — Alternate Clinical Information. Indicate the relevant drug class for the request, whether the member is new to ForwardHealth, and provide information on any previous use of the requested non-preferred drug.
6. In Sections V and VI, provide details relevant to pharmacy providers, including National Drug Code, days’ supply requested, and additional information necessary for the request.
7. After filling out all sections, review the form for accuracy. Finally, you may save the changes, download, print, or share the completed form as needed.

Complete your WI DHS F-11075 form online today to ensure timely access to necessary medications.