Pharmacy

Table of Contents
Preface .......................................................................................................................... 3
Obtaining Prior Authorization ......................................................................................... 5
The Wisconsin STAT-PA System ................................................................................. 5
Follow-Up to a STAT-PA Request .......................................................................... 5
Special STAT-PA Circumstances............................................................................. 6
Dispensing STAT-PA Drugs When the STAT-PA System is Unavailable ................. 6
Change From One Ulcer Treatment Drug or Angiotensin Converting Enzyme
Inhibitor to Another ........................................................................................ 6
Paper Prior Authorization........................................................................................... 7
Obtaining Forms .................................................................................................. 7
Submitting Forms by Mail or Fax ........................................................................... 7
Follow-Up to a Paper Prior Authorization Request ................................................... 7
Covered Rebated Drug Categories That Require Paper Prior Authorization Requests .. 7
Covered Non-Rebated Drugs That Require Paper Prior Authorization Requests ......... 8
Documentation of Medical Necessity and Cost Effectiveness ................................ 8
Other Services Requiring Paper Prior Authorization................................................. 8
Prior Authorization for HealthCheck “Other Services” ......................................... 8
Diagnosis-Restricted Drugs .............................................................................. 9
Prior Authorization Response Time........................................................................... 10
24-Hour Response ............................................................................................. 10
Weekend and Holiday Processing .................................................................... 10
Exceptions to the 24-Hour Response............................................................... 10
Backdating Prior Authorizations ................................................................................ 10
Appendix .................................................................................................................... 11
1. STAT-PA System Instructions ................................................................................... 13
2. STAT-PA Drug Worksheet: Ulcer Treatment Drug (Histamine 2 Antagonist) (for
photocopying) ............................................................................................................. 19
3. STAT-PA Drug Worksheet: Non-Steroidal Anti-Inflammatory Drugs (for photocopying) 23
4. STAT-PA Drug Worksheet: Alpha-1 Proteinase Inhibitor (Prolastin) (for photocopying) 27
5. STAT-PA Drug Worksheet: C-III and C-IV Stimulants and Anti-Obesity Drugs (for
photocopying) ............................................................................................................. 31
6. STAT-PA Drug Worksheet: Angiotensin Converting Enzyme Inhibitors (for
photocopying) ............................................................................................................. 35
7. Prior Authorization Request Form Completion Instructions ......................................... 39
8 Sample Prior Authorization Request Form .................................................................. 43
9. Prior Authorization Drug Attachment Completion Instructions For Legend Drugs and
Enteral Nutrition Products ............................................................................................. 45
10. Prior Authorization Drug Attachment For Legend Drugs (for photocopying) ............... 47
11. Prior Authorization Drug Attachment For Enteral Nutrition Products (for
photocopying) ............................................................................................................. 49
PHC 1354E