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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-11049 Prior Authorization/Drug Attachment (PA/DGA) DMS English 01/2024 Word No
F-11049A Prior Authorization/Drug Attachment (PA/DGA), Instructions DMS English 01/2024 PDF No
F-11054 Prior Authorization/Enteral Nutrition Formula Attachment (PA/ENFA) DMS English 06/2023 PDF No
F-11054 Prior Authorization/Enteral Nutrition Formula Attachment (PA/ENFA) DMS English 06/2023 Word No
F-11054A Prior Authorization/Enteral Nutrition Formula Attachment (PA/ENFA), Completion Instructions DMS English 06/2023 PDF No
F-00212 Prior Authorization/Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery/Treatment Plan Attachment DMS English 02/2010 Word No
F-00212 Prior Authorization/Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery/Treatment Plan Attachment DMS English 02/2010 PDF No
F-00212A Prior Authorization/Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery/Treatment Plan Attachment Instructions DMS English 12/2019 PDF No
F-11034 Prior Authorization/Physician-Administered Drug Attachment (PA/PAD) DMS English 07/2022 PDF No
F-11034 Prior Authorization/Physician-Administered Drug Attachment (PA/PAD) DMS English 07/2022 Word No
F-11034A Prior Authorization/Physician-Administered Drug Attachment (PA/PAD) Instructions DMS English 07/2022 PDF No
F-02572 Prior Authorization/Preferred Drug List (PA/PDL) for Immunomodulators, Atopic Dermatitis – Topical DMS English 10/2024 Word No
F-11075 Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request DMS English 07/2023 Word No
F-11075 Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request DMS English 07/2023 PDF No
F-11075A Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request, Instructions DMS English 07/2023 PDF No
F-01674 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa DMS English 01/2017 PDF No
F-01674 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa DMS English 01/2017 Word No
F-01674A Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa Completion Instructions DMS English 01/2017 PDF No
F-02433 Prior Authorization/Preferred Drug List (PA/PDL) for Epidiolex DMS English 04/2021 PDF No
F-02433 Prior Authorization/Preferred Drug List (PA/PDL) for Epidiolex DMS English 04/2021 Word No
F-02433A Prior Authorization/Preferred Drug List (PA/PDL) for Epidiolex, Instructions DMS English 04/2021 PDF No
F-11092 Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs DMS English 07/2024 PDF No
F-11092 Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs DMS English 07/2024 Word No
F-11092A Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs Instructions DMS English 07/2024 PDF No
F-02572 Prior Authorization/Preferred Drug List (PA/PDL) for Immunomodulators, Atopic Dermatitis – Topical DMS English 10/2024 PDF No
F-02572A Prior Authorization/Preferred Drug List (PA/PDL) for Immunomodulators, Atopic Dermatitis – Topical, Instructions DMS English 10/2024 PDF No
F-00622A Prior Authorization/Preferred Drug List (PA/PDL) for Migraine Agents, Injectable Completion Instructions DMS English 07/2015 PDF No
F-00280A Prior Authorization/Preferred Drug List (PA/PDL) for Migraine Agents, Other Completion Instructions DMS English 07/2015 PDF No
F-00079A Prior Authorization/Preferred Drug List (PA/PDL) for Modafinil and Nuvigil Completion Instructions DMS English 01/2017 PDF No
F-01672 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Preferred Stimulants DMS English 01/2017 PDF No
F-01672 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Preferred Stimulants DMS English 01/2017 Word No
F-01672A Prior Authorization/Preferred Drug List (PA/PDL) for Non-Preferred Stimulants, Instructions DMS English 01/2022 PDF No
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) DMS English 01/2018 Word No
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) DMS English 01/2018 PDF No
F-11077A Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Instructions DMS English 01/2022 PDF No
F-00081 Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents—Buprenorphine DMS English 07/2024 PDF No
F-00081 Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents—Buprenorphine DMS English 07/2024 Word No
F-00081A Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents—Buprenorphine Instructions DMS English 07/2024 PDF No
F-01673 Prior Authorization/Preferred Drug List (PA/PDL) for Orexin Receptor Antagonists DMS English 04/2022 PDF No
F-01673 Prior Authorization/Preferred Drug List (PA/PDL) for Orexin Receptor Antagonists DMS English 04/2022 Word No
F-01673A Prior Authorization/Preferred Drug List (PA/PDL) for Orexin Receptor Antagonists, Instructions DMS English 04/2022 PDF No
F-11078 Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules, Suspensions, and Non-Orally Disintegrating Tablets DMS English 07/2022 PDF No
F-11078 Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules, Suspensions, and Non-Orally Disintegrating Tablets DMS English 07/2022 Word No
F-11078A Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules, Suspensions, and Non-Orally Disintegrating Tablets Instructions DMS English 07/2022 PDF No
F-00433 Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets DMS English 07/2022 PDF No
F-00433 Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets DMS English 07/2022 Word No
F-00433A Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets Instructions DMS English 07/2022 PDF No
F-11041 Private Duty Nursing Prior Authorization Acknowledgment DMS English 10/2008 Word No
F-11041 Private Duty Nursing Prior Authorization Acknowledgment DMS English 10/2008 PDF No
F-02577 Proof of In-Kind Hours DMS English 06/2023 PDF No

Glossary

 
Last revised January 24, 2023