Prior Auth Required

13074 - (07/12)) form

This procedure appears on the selected insurer prior authorization source.

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Prior authorizationPrior Auth Required
Procedure / Service(07/12)) form
Procedure / Service Description

Wisconsin Medicaid - ❍ In certain circumstances, drug claims must be submitted on paper with a Pharmacy Special Handling Request (F- 13074 (07/12)) form. ❍ Claims submitted with four or more NDCs (National Drug Codes) for compound and noncompound drugs with

Likely documents
  • Confirm benefit details
  • Submit clinical notes if requested by the plan
Next actions
  • Confirm the current plan policy before submission.
  • Use the insurer authorization workflow for this listed code.