Suboxone Wellcare PDF Details

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.

Form NameSuboxone Wellcare
Form Length1 pages
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#






Date Submitted

DEA# (including X)


Prescriber Name



Alternate Phone


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


____________ 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.


Does patient currently abuse alcohol? [ ] Yes [

] No



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


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


State Approved 10032012

©WellCare 2012 GA_08_12


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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