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Wisconsin Medicaid PA/DGA F-11049: Drug Attachment

ForwardHealth uses this four-page attachment for drugs that need prior authorization when no drug-specific form applies. Wisconsin carves pharmacy out to fee-for-service for all members, so the form applies regardless of HMO enrollment. The prescriber documents the prescription and clinical rationale, and the pharmacy must have the completed form before submitting the PA request.

Who completes it

The prescriber completes the member, prescription and clinical information, fills whichever of Sections IV through VIII applies, and signs Section IX. The pharmacy provider then uses the completed form to submit the request.

Submitting and payment

How to submit it
The pharmacy submits the PA request through the ForwardHealth Portal or STAT-PA, or by fax or mail with the PA/RF, and must have the completed PA/DGA before submitting.

Good to know

  • Section IV is for HealthCheck 'Other Services' requests, limited to members under 21, and needs the date of the latest HealthCheck screen and the Medicaid-enrolled screener's name.
  • Section V covers diagnosis-restricted drugs and asks for peer-reviewed literature on efficacy and safety for the requested use, plus prior treatments and why they were stopped or not used.
  • For a non-preferred PDL drug in Section VII, explain specifically why preferred PDL drugs cannot be used. The related F-11075 PA/PDL Exemption Request covers non-preferred drugs too.
  • About 35 drug-specific PA/DGA and PA/PDL forms exist, for example for GLP-1 agents, stimulants, hepatitis C and MS agents. Completion instructions for this general form are in F-11049A.

Get the official form

Download the current version from the source each time; forms change without notice.

Prior Authorization/Drug Attachment (PA/DGA)

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

When should the general PA/DGA be used instead of a drug-specific form?

Use the PA/DGA when a drug needs prior authorization and ForwardHealth has no drug-specific form for it. Wisconsin has about 35 drug-specific PA/DGA and PA/PDL forms, covering classes such as GLP-1 agents, weight management, stimulants and hepatitis C, and those forms are used for their drugs.

What extra documentation do out-of-state pharmacies need?

Section VII notes that when an out-of-state pharmacy provides a non-emergency service and the drug has no specific PA criteria, documentation must show, with medical records, that the member has a condition for which the drug has FDA approval, and that it is prescribed consistent with FDA-approved labeling.

Does the PA/DGA apply to BadgerCare Plus HMO members?

Yes. Wisconsin carves pharmacy out to fee-for-service for all Medicaid and BadgerCare Plus members, so drug prior authorization goes through ForwardHealth even when the member is enrolled in an HMO. The prescriber's completed PA/DGA supports the pharmacy's request.