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BadgerCare Plus Forms

Below is a list of all BadgerCare Plus forms. 

When you are searching for a document, enter the number or a portion of the title in the search box below.

Assigned Number Title Division Language Release Date File Type Available to Order
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use DMS English 03/2023 Word No
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use DMS English 03/2023 PDF No
F-13074 Pharmacy Special Handling Request DMS English 04/2014 Word No
F-13074 Pharmacy Special Handling Request DMS English 04/2014 PDF No
F-13074A Pharmacy Special Handling Request: Completion Instructions DMS English 07/2012 PDF No
F-00401 Preferred Drug List (PDL) Expedited Emergency Supply Request DMS English 01/2021 Word No
F-00401 Preferred Drug List (PDL) Expedited Emergency Supply Request DMS English 01/2021 PDF No
F-00401A Preferred Drug List (PDL) Expedited Emergency Supply Request, Instructions DMS English 01/2021 PDF No
F-03185 Prenatal Care Coordination Care Coordinator Visit Checklist DMS English 06/2023 PDF No
F-03185 Prenatal Care Coordination Care Coordinator Visit Checklist DMS English 06/2023 Word No
F-03183 Prenatal Care Coordination Care Plan DMS English 06/2023 PDF No
F-03183 Prenatal Care Coordination Care Plan DMS English 06/2023 Word No
F-03183A Prenatal Care Coordination Care Plan, Instructions DMS English 06/2023 PDF No
F-03186 Prenatal Care Coordination Monthly Time Log for Ongoing Care Coordination and Monitoring DMS English 12/2023 PDF No
F-03186 Prenatal Care Coordination Monthly Time Log for Ongoing Care Coordination and Monitoring DMS English 12/2023 Word No
F-03186A Prenatal Care Coordination Monthly Time Log for Ongoing Care Coordination and Monitoring, Instructions DMS English 12/2023 PDF No
F-03188 Prenatal Care Coordination Plan of Operation DMS English 06/2023 PDF No
F-03188 Prenatal Care Coordination Plan of Operation DMS English 06/2023 Word No
F-01105 Prenatal Care Coordination Pregnancy Questionnaire DMS English 07/2024 Word No
F-01105 Prenatal Care Coordination Pregnancy Questionnaire DMS English 07/2024 PDF No
F-01105A Prenatal Care Coordination Pregnancy Questionnaire Instructions DMS English 07/2024 PDF No
F-01105AH Prenatal Care Coordination Pregnancy Questionnaire Instructions, Hmong DMS Hmong 07/2024 PDF No
F-01105AS Prenatal Care Coordination Pregnancy Questionnaire Instructions, Spanish DMS Spanish 07/2024 PDF No
F-01105H Prenatal Care Coordination Pregnancy Questionnaire, Hmong DMS Hmong 07/2024 PDF No
F-01105H Prenatal Care Coordination Pregnancy Questionnaire, Hmong DMS English 07/2024 Word No
F-01105S Prenatal Care Coordination Pregnancy Questionnaire, Spanish DMS Spanish 07/2024 PDF No
F-01105S Prenatal Care Coordination Pregnancy Questionnaire, Spanish DMS English 07/2024 Word No
F-03187 Prenatal Care Coordination Referral DMS English 12/2023 PDF No
F-03187 Prenatal Care Coordination Referral DMS English 12/2023 Word No
F-03187A Prenatal Care Coordination Referral, Instructions DMS English 12/2023 PDF No
F-03184 Prenatal Care Coordination Training Plan DMS English 06/2023 PDF No
F-03184 Prenatal Care Coordination Training Plan DMS English 06/2023 Word No
F-00704 Prior Authorization - Committee Public Testimony Registration DMS English 08/2016 PDF No
F-00701 Prior Authorization - Drug Attachment for Onabotulinumtoxin A (Botox®) to Treat Chronic Migraines DMS English 08/2019 PDF No
F-00701 Prior Authorization - Drug Attachment for Onabotulinumtoxin A (Botox®) to Treat Chronic Migraines DMS English 08/2019 Word No
F-00701A Prior Authorization - Drug Attachment for Onabotulinumtoxin A (Botox®) to Treat Chronic Migraines Completion Instructions DMS English 08/2013 PDF No
F-00694 Prior Authorization - Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ulcerative Colitis DMS English 12/2013 PDF No
F-11038 Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) DMS English 07/2012 PDF No
F-11038 Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) DMS English 07/2012 Word No
F-11038A Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA): Completion Instructions DMS English 07/2012 PDF No
F-01629 Prior Authorization / Behavioral Treatment Attachment (PA/BTA) DMS English 12/2019 PDF No
F-01629 Prior Authorization / Behavioral Treatment Attachment (PA/BTA) DMS English 12/2019 Word No
F-01629A Prior Authorization / Behavioral Treatment Attachment (PA/BTA) Completion Instructions DMS English 12/2019 PDF No
F-11011 Prior Authorization / Birth to 3 Attachment (PA/B3) DMS English 07/2012 Word No
F-11011 Prior Authorization / Birth to 3 Attachment (PA/B3) DMS English 07/2012 PDF No
F-11096 Prior Authorization / Care Plan Attachment (PA/CPA) DMS English 08/2015 Word No
F-11096 Prior Authorization / Care Plan Attachment (PA/CPA) DMS English 08/2015 PDF No
F-11096A Prior Authorization / Care Plan Attachment (PA/CPA): Completion Instructions DMS English 09/2015 PDF No
F-11040 Prior Authorization / Child / Adolescent Day Treatment Attachment (PA/CADTA) DMS English 12/2019 Word No
F-11040 Prior Authorization / Child / Adolescent Day Treatment Attachment (PA/CADTA) DMS English 12/2019 PDF No

Glossary

 
Last revised January 24, 2023