Wisconsin Medicaid Prior (Rx) Authorization Form

Updated January 23, 2022

A Wisconsin Medicaid prior authorization form is a request form submitted by a physician who believes it is medically necessary to prescribe their patient a specific medication. Typically, Medicaid covers a wide range of prescriptions for their members but some medications must be put through a prior authorization procedure. The idea behind this is to make sure patients are receiving the most appropriate and cost-effective treatment available to avoid the misutilization of unnecessary medical services. The review board takes a number of variables into consideration such as provider certification, recipient eligibility, and medical necessity, before choosing to reimburse the prescription in question. We have provided the preferred drug list (PDL) below which includes all of the medications currently being covered by Wisconsin Medicaid.

Form can be faxed to: 1 (608) 221-8616

Phone number: 1 (800) 947-9627

Preferred Drug List

Wisconsin Medicaid Prior Authorization Fax Cover Sheet

How to Write

Step 1 – Section 1 of the request form asks for the full name of the member, their ID number, and their date of birth.

Step 2 – In Section II (2), provide the name of the drug being requested, the strength, the date of prescription, and directions for administration. The second part of section 2 asks for the name of the prescriber, their NPI number, address, and phone number.

Step 3 – The next section is “Clinical Information”. Enter the diagnosis code and description, the drug class it belongs to, and in part (14.) include any previous drugs the patient has been prescribed along with the negative effects.

Step 4 – On page 2 section III (3) is continued. Answer yes or no to the question in part (15.) and, if the answer was yes, list the drugs and interactions in the space provided. Part (16.) asks if the patient has a medical condition that is preventing them from taking a drug from the PDL. Answer yes or no, and provide the reasoning in the space provided if the answer was yes.

Step 5 – Section IV (4) should be filled out for eligible drug classes only. Indicate the drug class at the top by selecting one of the 8 options. Answer yes or no to questions in part (18.), (19.), and (20.). If “yes” was selected, enter the date appropriate to each situation.

Step 6 – The prescriber must include their signature at the bottom of the page and the date.

Step 7 – For providers using STAT-PA, they should also fill in Section V (5) on the third page of the prior authorization form. This includes the national drug code, days supply, NPI number, date of service, place of service, assigned PA number, grant date, expiration date, number of days approved, and any additional information as deemed necessary by the provider.