Suboxone Wellcare PDF Details

Managing the treatment of opioid addiction requires careful coordination and adherence to specific medical guidelines. The Suboxone Wellcare form is a critical document in this process, designed to streamline the prescription process for Suboxanereg; and other forms of buprenorphine. This comprehensive form, required to be filled out by physicians with a Drug Addiction Treatment Act (DATA) waiver, gathers essential information about the patient, including their Member ID, name, phone number, diagnosis, and the prescribing physician’s details like DEA and NPI numbers. Physicians must indicate the specific medication and dosage requested, adhering to strict limits that prohibit doses above 32 mg per day. The form prompts for key details related to the patient's treatment history and current status, such as primary diagnosis, recent psychosocial counseling, compliance with treatment sessions, current alcohol use, opioid use within the last 30 days, and reasons for exceeding standard dosing limits, if applicable. It also requires information on planned psychosocial counseling and a urine drug screen. This document must be signed by the physician, certifying their waiver to prescribe these treatments, and submitted via fax to WellCare Pharmacy, signifying a controlled and monitored approach to opioid addiction treatment. By providing a structured format for requesting medication like Suboxone, this form plays a pivotal role in ensuring patients receive the appropriate, sanctioned care for their recovery journey.

QuestionAnswer
Form NameSuboxone Wellcare
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswellmed prior authorization form, uhc wellmed prior authorization form, wellmed provider forms, wellcare frm prior form

Form Preview Example

Member ID#

Name

Phone

Dx

Diagnosis

SPECIALTY

Date Submitted

DEA# (including X)

NPI #

Prescriber Name

FAX

Phone

Alternate Phone

Contact

Form must be completed, signed and submitted by a physician with a Drug Addiction Treatment Act (DATA) waiver** (UIN #)

Drug Requested:

[

] Suboxone® SL Film Tab 8mg/2mg

[

] Suboxone® SL Film Tab 2mg/0.5mg

[

] buprenorphineSL Tab 8mg

[

] buprenorphineSL Tab 2mg

Quantity:

____________ Sig: ________________________________

Start date of this PA: ______________

**Doses above 32 mg per day will NOT be approved.

1.Primary Diagnosis: ICD-9: _______________________________________________________

2.Psychosocial Counseling: __________________________________________________________

a. Date of last psychosocial counseling session: _______________________________________

b. Has patient been compliant with all sessions? [ ] Yes [ ] No

3.Please provide plan for method and dates (next 3) of psychosocial counseling going forward:

a.Method: _____________________________________________________________________

b.Dates: (1) _________________ (2) ___________________ (3) _________________________

4.Must submit most current urine drug screen with this form.

5.

Does patient currently abuse alcohol? [ ] Yes [

] No

 

6.

Has patient taken opioids in the past 30 days?

[

] Yes [

] No

 

a. If yes, please state reason for opioid use: _________________________________________

 

b. If yes, has patient experienced a relapse in disease?

[ ] Yes [ ] No

7.

If requesting doses above 24 mg per day, state clinical reason current dosing limits are being

 

exceeded: ______________________________________________________________________

 

a. Has patient tried a dose of 16 mg per day?

[

] Yes [

] No

b. If yes, provide dates of therapy: ____________________________________________________

8.Please indicate a taper schedule if dose exceeds 16 mg/day buprenorphine: __________________

_______________________________________________________________________________

**I certify that I have a Drug Addiction Treatment Act (DATA) waiver.

Physician Signature ___________________________________________ Date _________________

FAX to: WellCare Pharmacy 1-866-455-6558

GA020239_PRO_FRM__ENG

State Approved 10032012

©WellCare 2012 GA_08_12

48590

How to Edit Suboxone Wellcare Online for Free

There is nothing hard regarding filling in the wellmed prior authorization if you use our PDF editor. By following these basic steps, you can obtain the ready document in the least time frame you can.

Step 1: Hit the orange button "Get Form Here" on the web page.

Step 2: You're now on the file editing page. You may edit, add text, highlight certain words or phrases, place crosses or checks, and insert images.

You should enter the following details to complete the wellmed prior authorization PDF:

wellmed prior authorization fax request form gaps to fill in

Enter the requested particulars in a Date of last psychosocial, b Has patient been compliant with, Yes, Please provide plan for method, a Method, b Dates, Must submit most current urine, Does patient currently abuse, Yes, Has patient taken opioids in the, Yes, a If yes please state reason for, b If yes has patient experienced a, Yes, and If requesting doses above mg per part.

Filling out wellmed prior authorization fax request form part 2

Step 3: After you hit the Done button, the final document is readily transferable to any of your gadgets. Or, you will be able to send it by means of email.

Step 4: Create a minimum of a couple of copies of the file to keep away from any sort of possible future issues.

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