Get Wellcare Coveage Determination Form

Filling out the Wellcare Coverage Determination Form online can streamline the process of obtaining necessary medications. This guide will provide clear, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete the Wellcare Coverage Determination Form online.

1. Press the ‘Get Form’ button to obtain the Wellcare Coverage Determination Form and open it in your preferred document editor.
2. Identify who is making the request. Select from options such as 'Member' or 'Provider.' If you are an appointed representative, make sure to include a signed Appointment of Representative form (CMS-1696).
3. Fill in the member's name and date of request. Ensure that the WellCare ID number and state are correctly entered.
4. Provide the physician's name, date of birth, and indicate if the patient is currently in long-term care (LTC) by selecting 'Yes' or 'No.'
5. Complete the physician's signature, phone number, fax number, and specialty details.
6. State the diagnosis of the requested medication clearly.
7. Input the medication requested, including the dose, dosage form, directions for use, quantity, and duration of therapy.
8. Provide the pharmacy's phone number and fax number.
9. Include a clinical reason for the override, detailing any previous medications tried and failed, as well as any other pertinent information. If needed, fax additional supporting pages.
10. If expedited review is required, check the designated box. Confirm that applying the standard review timeframe may jeopardize the member's health. This certification must come from the prescribing physician or their agent.
11. Once all sections are filled, save any changes you made to the form. You can also download, print, or share the form as necessary.

Start filling out your Wellcare Coverage Determination Form online today!