If you are like most people, you have never heard of a wellcare prior authorization form. However, if you have ever needed to get prior approval for treatment from your insurance company, then you have filled out this form. The wellcare prior authorization form is a document that you need to fill out in order to get approval from your insurance company for certain treatments or procedures. The form can be used for both medical and dental procedures. If you are planning on undergoing a procedure that requires prior authorization from your insurance company, be sure to download and fill out the wellcare prior authorization form.
You will discover more info about the wellcare prior authorization form by looking through the table we compiled.
| Question | Answer |
|---|---|
| Form Name | Wellcare Prior Authorization Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | wellcare prior auth forms, wellcare prior authorization form, wellcare prior authorization pharmacy form, wellcare michigan prior authorization form |
Rev. 12/07
Medicare Coverage Determination Request Form
Instructions: This form is used to determine coverage for prior authorizations,
Who is making this request? Physician □ Member □ Pharmacy □ Appointed Representative □
The following review criteria are used in reviewing drug evaluations and requests for overrides:
•Patient has tried and failed an appropriate trial of generic or preferred medications.
•Other therapeutically equivalent medications are contraindicated in the patient.
•Choices available are not suited for the present patients care and the medication requested is required for patient safety.
•An alternative choice may provoke an underlying medical condition, which would be detrimental to the care of the patient.
Complete each section legibly and completely (include any additional necessary medical records)
Member Name |
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Date of Request |
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WellCare ID # |
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State: |
Physician Name |
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Date of Birth |
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Pt currently in LTC? |
Physician Signature |
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Yes or No |
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Member’s Telephone Number |
Specialty |
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Diagnosis of Requested Medication |
Sent by |
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Medication Requested |
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Physician Phone # |
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Dose |
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Dosage Form |
Physician Fax # |
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Directions for Use |
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Quantity |
Pharmacy Phone # |
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Duration of Therapy |
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Pharmacy Fax # |
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Clinical reason for override (previous medications tried and failed and any other pertinent |
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Details). Please fax additional supporting pages as necessary. |
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REQ UEST FO R EX PEDITED REV IEW (2 4 HO URS) |
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BY C HEC KING THIS BO X, |
THE PRESC RIBING PHYSIC IA N INDIC A TED A BO VE O R PHYSIC IA N’ S A G ENT |
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C ERTIFIES THA T A PPLYING THE 72 HO UR STA NDA RD REVIEW TIM E FRA M E M A Y SERIO USLY JEO PA RDIZE THE LIFE O R HEA LTH O F THE M EM BER O R THE M EM BER’ S A BILITY TO REG A IN M A XIM UM FUNC TIO N.
FAX to: WellCare Pharmacy |
For Internal Use Only |