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1234567890 Recipient, Ima A. MM/DD/YYYY I.M. Provider 1 W. Williams Anytown, WI 55555 MM/DD/YYYY Appendix 8 Sample Prior Authorization Request Form 1234567 X 609 Willow Anytown, WI 55555 XXX XXX-XXXX 12345678 AIDS-related Kaposi’s Sarcoma 64365050101 0 D Panretin 0.1% gel 60 gm XX.XX XX.XX <strong>Pharmacy</strong> Handbook — Prior Authorization Section K July 2001 43 131 Appendix
Appendix 44 Wisconsin Medicaid and BadgerCare K July 2001
Page 1 and 2: Pharmacy Prior rior rior Authoriza
Page 3 and 4: Important Telephone Numbers Wiscons
Page 5 and 6: 12. Prior Authorization Fax Procedu
Page 7 and 8: Wisconsin Law and Regulation • La
Page 9 and 10: Obtaining Prior Authorization When
Page 11 and 12: Obtaining Prior Authorization Reque
Page 13 and 14: Obtaining Prior Authorization Prior
Page 15 and 16: Appendix
Page 17 and 18: Appendix This software and user man
Page 19 and 20: Appendix 5. In the event the STAT-P
Page 21 and 22: Appendix 8. To tag a file for downl
Page 23 and 24: Appendix 20 Wisconsin Medicaid and
Page 25 and 26: As the pharmacist, you have learned
Page 29 and 30: Non-COX-2 A. Has the recipient trie
Page 43 and 44: Appendix Element 10 — Dx: Primary
Page 45: Appendix 42 Wisconsin Medicaid and
Page 49 and 50: Appendix Section A — Type of Requ
Page 51 and 52: Mail To: Wisconsin Medicaid Prior A
Page 55 and 56: Source for Clinical Information (ch
Page 61 and 62: Appendix Drug Name or Category Bran
Page 63 and 64: Appendix Drug Approval Criteria Spe
Page 71 and 72: All of the Following Procedures Are
Page 73 and 74: Glossary EMC Electronic Media Claim
Page 75 and 76: Glossary STAT-PA Specialized Transm

Pharmacy

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