Get Drug Evaluation

Filling out the Drug Evaluation form can be a critical step in obtaining necessary medication coverage. This guide will provide clear and concise instructions on how to complete each section of the form to ensure a smooth and efficient process.

Follow the steps to successfully complete your Drug Evaluation form.

1. Press the ‘Get Form’ button to obtain the Drug Evaluation form and open it in your preferred editor.
2. Complete the member name section by entering the full name of the individual in need of medication coverage.
3. Fill in the date of request to indicate when the evaluation is being submitted.
4. Provide the health plan ID number associated with the member for proper identification.
5. Select the appropriate health plan from the available options to ensure accurate processing.
6. Enter the date of birth of the member to verify their identity and eligibility.
7. Input the name of the physician making the request, as this will be crucial for follow-up communications.
8. Clearly state the diagnosis related to the medication need to facilitate the evaluation process.
9. Indicate the specialty of the physician submitting the form for relevant context.
10. Write the name of the drug being requested for coverage, ensuring that it aligns with the diagnosis.
11. Add the name of the person sending the form, as it helps in tracking the submission.
12. Provide the dosage information, including instructive directions for the medication.
13. Include the physician’s phone number for any potential queries regarding the request.
14. Document the dosage form used, such as tablet, liquid, or injection, to specify how the drug will be administered.
15. Input the physician’s fax number to facilitate communication regarding approval.
16. Enter the strength of the medication, which is critical for the accurate assessment of the request.
17. Specify the quantity of the drug being requested to avoid any confusion in filling the prescription.
18. Provide the pharmacy phone number for assistance or verification if necessary.
19. Indicate the length of treatment required, which will help the committee evaluate the case.
20. Clearly detail the clinical reason for the override request, and include any necessary medical documentation.
21. List any previous medications that have failed, providing details about each drug, dose, and strength.
22. Fill out the history section and any additional comments that could support the request.
23. Complete the internal use section by noting the date, who was spoken to, and any pertinent comments.
24. Review all entered information for accuracy before preparing to submit the form.
25. Once completed, fax the form to WellCare Pharmacy at (813) 290-6277 or (813) 290-6337.

Complete your Drug Evaluation form online today for efficient medication coverage.