Form F-13074 "Pharmacy Special Handling Request" - Wisconsin

What Is Form F-13074?

This is a legal form that was released by the Wisconsin Department of Health Services - a government authority operating within Wisconsin. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2014;
  • The latest edition provided by the Wisconsin Department of Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form F-13074 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

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Download Form F-13074 "Pharmacy Special Handling Request" - Wisconsin

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-13074 (04/14)
FORWARDHEALTH
PHARMACY SPECIAL HANDLING REQUEST
Instructions: Providers may submit the Pharmacy Special Handling Request and paper drug claim to ForwardHealth, Pharmacy
Special Handling Unit, Suite 20, 313 Blettner Boulevard, Madison, WI 53784. Type or print clearly. Refer to the Pharmacy Special
Handling Request Completion Instructions, F-13074A, for more information.
SECTION I — PROVIDER INFORMATION
1. National Provider Identifier
2. Telephone Number — Provider
3. ForwardHealth Program
 Wisconsin Medicaid.
 BadgerCare Plus Standard Plan.
 SeniorCare.
 Wisconsin Chronic Disease Program.
SECTION II — REASON FOR REQUEST (Choose one.)
 4. Policy Review Request (In the space below, include the Explanation of Benefits (EOB) number, reason for policy review, and
any additional information.)
 5. Emergency Supply Request (In the space below, include the type of prior authorization (PA), Internal Control Number, EOB
number, and any additional information.)
Indicate the type of PA request from the options listed:
 Brand Medically Necessary.
 Clinical PA / Diagnosis Restriction.
 Preferred Drug List.
SECTION III — CERTIFICATION
6. SIGNATURE — Pharmacist or Dispensing Physician
7. Date Signed
Reset Form
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-13074 (04/14)
FORWARDHEALTH
PHARMACY SPECIAL HANDLING REQUEST
Instructions: Providers may submit the Pharmacy Special Handling Request and paper drug claim to ForwardHealth, Pharmacy
Special Handling Unit, Suite 20, 313 Blettner Boulevard, Madison, WI 53784. Type or print clearly. Refer to the Pharmacy Special
Handling Request Completion Instructions, F-13074A, for more information.
SECTION I — PROVIDER INFORMATION
1. National Provider Identifier
2. Telephone Number — Provider
3. ForwardHealth Program
 Wisconsin Medicaid.
 BadgerCare Plus Standard Plan.
 SeniorCare.
 Wisconsin Chronic Disease Program.
SECTION II — REASON FOR REQUEST (Choose one.)
 4. Policy Review Request (In the space below, include the Explanation of Benefits (EOB) number, reason for policy review, and
any additional information.)
 5. Emergency Supply Request (In the space below, include the type of prior authorization (PA), Internal Control Number, EOB
number, and any additional information.)
Indicate the type of PA request from the options listed:
 Brand Medically Necessary.
 Clinical PA / Diagnosis Restriction.
 Preferred Drug List.
SECTION III — CERTIFICATION
6. SIGNATURE — Pharmacist or Dispensing Physician
7. Date Signed
Reset Form