If you are prescribed Suboxone, you know how important it is to have a medication adherence plan in place. The Suboxone Wellcare Form can help you keep track of your prescription and make sure you are taking your medication as directed. The form includes spaces for information on your name, address, phone number, doctor's name and contact information, the date of your last dose, and more. By keeping track of your dosage and intake schedule on the form, you can ensure that you are getting the most out of your treatment plan.
This article includes details about suboxone wellcare. Before you fill in the form, it is definitely worth reading through more about it.
| Question | Answer |
|---|---|
| Form Name | Suboxone Wellcare |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | wellmed authorization forms, wellcare frm prior blank, wellcare frm, wellmed authorization form |
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:
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: _________________________________________ |
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b. If yes, has patient experienced a relapse in disease? |
[ ] Yes [ ] No |
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7. |
If requesting doses above 24 mg per day, state clinical reason current dosing limits are being |
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exceeded: ______________________________________________________________________ |
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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
GA020239_PRO_FRM__ENG |
State Approved 10032012 |
©WellCare 2012 GA_08_12 |
48590 |