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Wisconsin Medicaid PA/PDL F-11075: PDL Exemption

Wisconsin Medicaid prescribers complete this three-page form to request coverage of a non-preferred drug on the Preferred Drug List. It documents why preferred drugs in the same class cannot be used: an unsatisfactory response or adverse reaction, a drug interaction, or a medical condition. The pharmacy needs the signed form before calling STAT-PA or submitting the request.

Who completes it

The prescriber completes Sections I through IV and signs. Section V is for pharmacy providers using STAT-PA, recording NDC, days' supply, date of service and the assigned PA number with grant and expiration dates.

Submitting and payment

How to submit it
The pharmacy submits the request through the STAT-PA system or the ForwardHealth Portal, or by fax or mail, with the prescriber-signed form on hand. Completion instructions are in F-11075A.

Good to know

  • Section III is required for all requests: diagnosis, the PDL drug class, and whether a preferred drug failed, caused a clinically significant reaction, interacts with another drug, or is ruled out by a condition.
  • Section IV offers alternate criteria for certain classes such as antipsychotics, antidepressants, anticonvulsants, HIV-AIDS and pulmonary arterial hypertension: new members, 30 days of stable use, or recent inpatient stabilization.
  • Under STAT-PA, days' supply can be up to 365 days, and the date of service can be up to 31 days in the future or 14 days in the past.
  • The general PA/DGA (F-11049) also handles non-preferred PDL drugs in its Section VII, where the prescriber explains why preferred drugs cannot be used.

Get the official form

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

Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request

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

What qualifies a member for a Wisconsin PDL exemption?

Section III asks whether the member had an unsatisfactory therapeutic response or a clinically significant adverse reaction to at least one preferred drug in the same class, a significant interaction with another drug, or a medical condition that prevents using a preferred drug. Drug names, dates and descriptions are required.

Which drug classes have alternate PDL criteria?

Section IV applies to Alzheimer's agents, anticonvulsants, other antidepressants, SSRIs, antiparkinson's agents, antipsychotics, HIV-AIDS drugs and pulmonary arterial hypertension drugs. It covers members new to ForwardHealth in the past month, members stable on the drug for 30 days or more, and recent inpatient stabilization.

Who signs the PA/PDL Exemption Request?

The prescriber signs and dates Element 21. The form states pharmacy providers must have it completed and signed by the prescriber before calling STAT-PA or submitting a PA request on the Portal, by fax or by mail.