Wellcare Prior Authorization Pharmacy Form Details

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.

QuestionAnswer
Form NameWellcare Prior Authorization Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswellcare prior auth forms, wellcare prior authorization form, wellcare prior authorization pharmacy form, wellcare michigan prior authorization form

Form Preview Example

Rev. 12/07

Medicare Coverage Determination Request Form

Instructions: This form is used to determine coverage for prior authorizations, non-formulary medications (see formulary listings at www.wellcare.com), and medications with utilization management rules. WellCare will evaluate the request based on medical criteria, FDA guidelines and protocols developed by the WellCare Pharmacy & Therapeutics Committee.

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

 

 

Date of Request

 

 

 

 

WellCare ID #

 

State:

Physician Name

 

 

 

 

Date of Birth

 

Pt currently in LTC?

Physician Signature

 

 

Yes or No

 

 

 

 

Member’s Telephone Number

Specialty

 

 

Diagnosis of Requested Medication

Sent by

 

 

 

 

Medication Requested

 

 

Physician Phone #

 

 

 

 

Dose

 

Dosage Form

Physician Fax #

 

 

 

 

Directions for Use

 

Quantity

Pharmacy Phone #

 

 

 

 

Duration of Therapy

 

 

Pharmacy Fax #

 

 

Clinical reason for override (previous medications tried and failed and any other pertinent

Details). Please fax additional supporting pages as necessary.

 

 

 

 

 

 

 

 

 

 

REQ UEST FO R EX PEDITED REV IEW (2 4 HO URS)

 

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

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 1-866-388-1767

For Internal Use Only