Transcription of FORWARDHEALTH PRIOR AUTHORIZATION / PREFERRED …
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FORWARDHEALTH PRIOR AUTHORIZATION / PREFERRED …
DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Health Care Access and Accountability Wis. Admin. Code DHS (2) F-01672 (01/2017) FORWARDHEALTH PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR NON- PREFERRED STIMULANTS Instructions: Type or print clearly. Before completing this form, read the PRIOR AUTHORIZATION / PREFERRED Drug List (PA/PDL) for Non- PREFERRED Stimulants Completion Instructions, F-01672A. Providers may refer to the Forms page of the FORWARDHEALTH Portal at for the completion instructions. Pharmacy providers are required to have a completed PRIOR AUTHORIZATION / PREFERRED Drug List (PA/PDL) for Non- PREFERRED Stimulants form signed by the prescriber before calling the Specialized Transmission Approval Technology- PRIOR AUTHORIZATION (STAT-PA) system or submitting a PA request on the Portal, by fax, or by mail.
Pharmacy providers are required to have a completed Prior Authorization/Preferred Drug List (PA/PDL) for Non-Preferred Stimulants form signed by the prescriber before calling the Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) system or submitting a PA request on the Portal, by fax, or by mail.
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