Prior Authorization : Services Requiring Prior Authorization

Drugs That Require Paper Prior Authorization

Paper PA request submission is required to determine medical necessity for the following drugs. Diagnosis and information regarding the medical requirements for these drug categories must be provided on the PA request for members enrolled in BadgerCare Plus, Wisconsin Medicaid, and SeniorCare:

• Alitretinoin gel (when used to treat Kaposi's sarcoma lesions)
• BBG drugs
• BMN drugs
• Diagnosis-restricted drugs that require PA outside approved diagnoses
• Drugs without signed manufacturer rebate agreements^*
• Fertility enhancement drugs (when used to treat conditions other than infertility)
• Impotence treatment drugs (when used for a condition other than impotence)
• Unlisted or investigational drugs^*

^* SeniorCare does not cover prescription drugs, even with a PA request, that do not have a signed rebate agreement between the Wisconsin DHS and the manufacturer; however, these drug products may be covered for BadgerCare Plus or Wisconsin Medicaid members if a paper PA request is submitted.

Submitting Paper Prior Authorization Requests

Paper PA requests that are faxed to ForwardHealth will receive an adjudication response via telephone one business day after they are received. Providers who submit PA requests by mail should be aware that this option requires additional time for the PA request to reach ForwardHealth and for ForwardHealth to complete the adjudication process.

To avoid delayed adjudication, do not fax and mail duplicate copies of the same PA request forms.

Pharmacy providers may contact Provider Services to determine the status of any PA request that has been submitted.

Approved, Returned, and Denied Paper Requests

A paper PA request submitted to ForwardHealth may be approved, returned, or denied.

When a PA request is approved:

• The "approved" box on the PA/RF is checked.
• The grant and expiration dates are indicated.
• A signature and a date signed are indicated.
• A specific days' supply is indicated.

When a PA request is returned:

• The "return" box on the PA/RF is checked.
• An explanation for the return is indicated.

A PA request is returned because additional information is needed or because information on the request must be corrected. A returned PA request is not the same as a denied request. Providers should correct or add the missing information to the original PA request and resubmit it to BadgerCare Plus or SeniorCare.

When a PA request is denied:

• The "denied" box on the PA/RF is checked and an explanation is given.
• A signature and date signed are indicated.