Gundersen Lutheran Health Plan utilizes and adopts nationally developed medical policies; commercially recognized criteria sets; regionally developed medical coverage policies; and locally produced specialty medical coverage policies. Additionally, the Health Plan involves appropriate practitioners in development, adoption and review of criteria and medical coverage policies. All criteria are available upon request by contacting the Health Plan Medical Management Department. A written copy can be sent electronically, by mail, or directly communicated via the telephone.

Prior Authorization

• Procedures and Services Requiring Prior Authorization (PA Grid) 
  • Prior Authorization Request Form
• Instructions regarding Senior Preferred Part B Therapies extending beyond 30 days  
  • Senior Preferred Part B Therapies Request Form

General Forms

• Referral Authorization
• Criteria Used for Durable Medical Equipment (DME)
• Provider/Practitioner Addition or Change Datasheet

Senior Preferred Forms - Iowa Residents

• Hospital Preadmission Denial Notice
• Detailed Notice of Discharge  
• Notice of Medicare Non-coverage: Home Health 
• Notice of Medicare Non-coverage: Skilled Nursing Facility
• Notice of Denial of Medical Coverage: Skilled Nursing Facility Admission 
  • What is this Notice?
• Notice of Denial of Medical Coverage: Hospital Observation Level of Care 
  • What is this Notice?
• Notice of Denial of Medical Coverage: Swing Bed
• Pre-Service Denial Notice
• Senior Preferred Personal Physician Change in Status 

Senior Preferred Forms - Wisconsin Residents

• Hospital Preadmission Denial Notice
• Detailed Notice of Discharge  
• Notice of Medicare Non-coverage: Home Health 
• Notice of Medicare Non-coverage: Skilled Nursing Facility
• Notice of Denial of Medical Coverage: Skilled Nursing Facility Admission 
  • What is this Notice?
• Notice of Denial of Medical Coverage: Hospital Observation Level of Care
  • What is this Notice?
• Notice of Denial of Medical Coverage: Swing Bed
• Pre-Service Denial Notice
• Senior Preferred Personal Physician Change in Status 

Pharmacy Forms for Healthcare Providers
If you have questions about the drug prior authorization process, please review the provider manual, or the drug prior authorization process overview.

• Employer Group Drug Prior Authorization
• Request for Medicare Prescription Drug Coverage Determination Form 
• Pharmacy and Therapeutic Committee: Formulary Request for Review

Completed forms should be sent to:

Gundersen Lutheran Health Plan
1836 South Avenue, Mail Stop: NCA2-01
La Crosse, WI 54601 or faxed to the number on the form.

Pharmacy Forms for Network Pharmacies

• Request for Prescription Information or Change form  (This form is for network pharmacies to use to alert a healthcare provider of the need for a prior authorization. Please note, this form is not sent to the health plan, but rather the healthcare provider.)