This information provides a summary of prior authorization requirements for medications.

The Formulary/Medication Restrictions list outlines the therapeutic classes for North Dakota Workforce Safety & Insurance (WSI)'s benefit plan. Medications listed on the formulary do not guarantee coverage and are subject to specific WSI policy and determination of appropriateness for the accepted conditions.

Medications on the formulary list will have one of three designated statuses:

  • (PA) Prior Authorization - requires prior authorization
  • (MDD) Max Daily Dose - limit on number times the drug can be taken per day
  • (C) Custom - medication not covered
    • Use the Formulary/Product Restrictions to find alternative medication.

Submitting a Prior Authorization for Medications with PA status

Submitting an Authorization for Brand Necessary Medications

Approval for a brand name medication which is specific to the medication, strength, and dosage is good for a maximum of one year.  To renew the authorization of a brand name medication, a provider must submit the M11 on an annual basis.

Submitting an Authorization for Medications Exceeding Maximum Daily Limits

Submitting an Authorization for Relistor(™)