To obtain prior authorization (PA) for brand medically necessary drugs, pharmacy providers are required to submit a MedWatch form, (PDF, 53 KB) Prior Authorization Request Form (PA/RF), or a Prior Authorization/Drug Attachment (PA/DGA), HCF 11049 (fillable PDF, 55 KB) (Rev. 06/03), to Wisconsin Medicaid. Providers are required to submit a photocopy of the brand medically necessary prescription with each PA request. The following table indicates the specific attachments providers are required to submit for certain PA requests.

Note: This table includes Wisconsin Medicaid’s most current information and may be updated periodically.

Brand Medically Necessary Prior Authorization Documentation Requirements
Scenario	Attachments
	PA/RF	PA/DGA	MedWatch form	Photocopy of prescription	Peer-reviewed medical literature
A drug has no restrictions (e.g., PA)
A drug currently requires PA
A drug is diagnosis restricted for an approved diagnosis
A drug is diagnosis restricted and is prescribed for use outside approved diagnoses

Attachment 1: Brand Medically Necessary Drugs That Require Prior Authorization
Attachment 3: MedWatch Reporting Form (FDA Web site) (PDF, 53 KB)
Attachment 4: Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) Drugs
Attachment 5: Drug Products Requiring Paper Prior Authorization
Attachment 6: Diagnosis-Restricted Drugs (Organized by Generic Drug Name)
Attachment 7: Diagnosis-Restricted Drugs (Organized by Diagnosis Code Description)
Attachment 8: Covered Over-the-Counter Drugs
Attachment 9: Noncovered Drugs
Attachment 10: Age- and Gender-Restricted Drugs
Attachment 11: Covered Over-the-Counter Drugs for HealthCheck "Other Services"
Attachment 12: Comparison of Wisconsin Medicaid and Wisconsin SeniorCare Policies
Attachment 13: Obsolete 1/1/05: STAT-PA Drug Worksheet for Brand Name Clozaril^® — Use Prior Authorization / Brand Medically Necessary Attachment (PA/BMNA) (fillable PDF, 225 KB)  | Instructions (PDF, 71 KB)

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