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Good Morning
11:23:26 AM CDT
Saturday, May 23, 2015

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

The Formulary/Medication Restrictions list outlines the therapeutic classes for 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:
  • (F) Formulary:
    Indicates the medication is available without prior authorization
  • (PA) Prior Authorization:
    Indicates the medication requires prior authorization before being dispensed to the injured worker. The pharmacies can start the authorization process for medication listed with a PA status
  • (N/F) Non-Formulary:
    Indicates the medication is not covered. Click here for an alternative medication listed on the WSI formulary
There are different authorization requirements depending on the medication and status of the medication:
  1. For medications with the status of PA:
    • Pharmacies can request authorization by contacting WSI at 701.328.3800 or 800.777.5033
    • OR
    • Physicians’ complete the Medication Authorization (P2) form (formally the M3 form)
    • Fax P2 form and supporting documentation to 701.328.3793
  2. Authorization of Brand Necessary medications (DAW1):
    • Physicians’ complete the Medication Authorization (P2) form
    • Fax P2 form and supporting documentation to 701.328.3793
      • Any approval for brand medication is specific to the medication, strength and dosage form.
  3. Authorization for Medications exceeding the maximum daily limits:
  4. Authorization for Relistor:
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