Get Wellcare Com Request For Coverage Form

The Wellcare Com Request For Coverage Form is essential for obtaining prior authorizations, particularly for non-formulary medications. This guide provides clear, step-by-step instructions to help users navigate the form's online submission process effectively.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to access the Wellcare Com Request For Coverage Form and open it in your designated document editor.
2. Identify who is making the request by selecting the appropriate option: Provider, Member, or Appointed Representative. If you select Appointed Representative, ensure you include a signed Appointment of Representative form.
3. Fill in the following member details: Member Name, Date of Request, and WellCare ID #. Ensure this information is accurate to avoid processing delays.
4. Provide the State where the member resides, and include the Physician's Name and Date of Birth. Specify whether the patient currently resides in Long-Term Care by selecting Yes or No.
5. Enter the Physician's Signature, along with their Telephone Number, Specialty, and the Diagnosis for the Requested Medication.
6. List the Medication Requested along with the Dose and Dosage Form. Include Directions for Use, Quantity, Duration of Therapy, and contact information for the Pharmacy, including the Phone # and Fax #.
7. Document the clinical rationale for the override/exception request. This includes listing names and doses of any previous medications the member has tried and failed.
8. If applicable, check the box for REQUEST FOR EXPEDITED REVIEW. By doing so, the prescribing physician certifies that applying the standard review time frame may jeopardize the member's health.
9. After filling out the form, review all sections for accuracy and completeness. You can then save changes, download, print, or share the form as needed.

Begin filling out the Wellcare Com Request For Coverage Form online now to ensure timely processing of your request.