Prescribers treating a North Dakota Workforce Safety & Insurance claim use the M11 when a medication, dosage or dosing interval needs prior authorization, or when the patient needs a brand-name drug instead of its generic. The request names the drug, strength, dosage form and diagnosis, and the prescriber certifies the medication is medically necessary and not prescribed for convenience or solely at the patient's request.
The prescribing provider completes all four sections, including NPI and facility, and signs the medical necessity certification in Section 4. The injured worker does not sign.
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Provider's Request for Medication Prior Authorization
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When the patient needs the brand product instead of its generic equivalent. WSI's policy requires a generic trial first, then an M11 showing objective medical evidence of an adverse reaction or an inadequate therapeutic response to the generic that the brand product does not cause or produce.
WSI's brand-necessary medication policy says approval applies to the specific medication, strength and dosage and is valid for a maximum of one year. The provider must submit the M11 each year to renew it, checking Renewal rather than Initial on the form.
That the medication is medically necessary for the patient's well-being, reasonable and necessary under accepted standards of medical practice for the condition, and not prescribed as a convenience to the patient or solely because the patient asked for it. The prescriber signs and dates that statement in Section 4.