Free ForwardHealth Drug Addition Review Request, F-00020 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-00020 (03/09)

STATE OF WISCONSIN

FORWARDHEALTH

DRUG ADDITION REVIEW REQUEST
Instructions: The use of this form is mandatory to request the review of a National Drug Code (NDC) for addition into a benefit plan The completed form may be returned to the Division of Health Care Access and Accountability via fax at (608) 266-1096 or by mail at the following address: Drug Price File Division of Health Care Access and Accountability PO Box 309 Madison WI 53701-0309 SECTION I -- PROVIDER INFORMATION Name -- Provider Address -- Provider (Street, City, State, ZIP Code) SECTION II -- NEW DRUG ADDITIONS NDC* (11 Digit No.) Drug Name Dispense Date Benefit Plan National Provider Identifier Taxonomy Code Telephone Number -- Provider ZIP+4 Practice Location Code

Medicaid / BadgerCare Plus Standard Plan / SeniorCare BadgerCare Plus Core Plan for Childless Adults BadgerCare Plus Benchmark Plan WCDP**, Chronic Renal Disease WCDP, Adult Cystic Fibrosis WCDP, Hemophilia Home Care Medicaid / BadgerCare Plus Standard Plan / SeniorCare BadgerCare Plus Core Plan for Childless Adults BadgerCare Plus Benchmark Plan WCDP**, Chronic Renal Disease WCDP, Adult Cystic Fibrosis WCDP, Hemophilia Home Care Medicaid / BadgerCare Plus Standard Plan / SeniorCare BadgerCare Plus Core Plan for Childless Adults BadgerCare Plus Benchmark Plan WCDP**, Chronic Renal Disease WCDP, Adult Cystic Fibrosis WCDP, Hemophilia Home Care Medicaid / BadgerCare Plus Standard Plan / SeniorCare BadgerCare Plus Core Plan for Childless Adults BadgerCare Plus Benchmark Plan WCDP**, Chronic Renal Disease WCDP, Adult Cystic Fibrosis WCDP, Hemophilia Home Care A -- Added as Requested; B -- Already Added; C -- Less-Than-Effective (LTE); D -- Not Eligible for Coverage
* NDC = National Drug Code. ** WCDP = Wisconsin Chronic Disease Program.

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