WellCare Prior (Rx) Authorization Form

Updated June 02, 2022

A WellCare Prior authorization form is a document used for requesting certain prescription drugs or covered/non-covered services. An individual’s policy might not cover certain drugs, procedures, or treatments, and a WellCare prior authorization form allows them, or the prescribing physician, to make a request for insurance coverage of the prescription in question. Not all patients will be granted coverage for the treatment/drug they are requesting just because a prior authorization form was submitted. WellCare often suggest a cheaper prescription or, in some cases, deny coverage for the requested drug and the patient will have to make the purchase out of pocket. WellCare provides government subsidized health coverage and these forms will only be applicable to those who qualify for medicaid/medicare.

  • Form can be faxed to: 1 (866) 825-2884

By State

How to Write

Step 1 – The “Priority” section of the WellCare prior authorization form asks what level of urgency the treatment/prescription must be delivered in. Select “standard” or “urgent” or request a date of service.

Step 2 – In the “Patient Information” section, enter the patient’s first and last name, date of birth, gender, height, weight, address, phone number, health plan ID#, and group#.

Step 3 – Section 3 requires the prescriber’s information, including name, TIN/NPI#, specialty, contact name, clinic name, clinic address, phone number, and fax/email.

Step 4 – The fourth section is to be filled out if the rendering physician/clinic/facility/pharmacy information is different from section 3. If they are the same, check the box provided on the right.

Step 5 – The last section of the first page is where the prescription/treatment information will be disclosed. Enter the service type and select the appropriate setting/CMS POS code. Use part (c) of section 5 if you ticked the box marked “Other”.

Step 6 – In section 6, enter the ICD code, the procedure code, code description, and the medical reason for prescribing the drug/treatment in question. Include any documentation with this prior authorization form to support your medical reasoning for prescribing this medication to your patient.

Step 7 – Section 7 may be filled out if other services are requested at this point in time that are related to the medication the patient requires.

Step 8 – In the “Prescription Drug” section, enter the diagnosis name and code, the requested medication and the strength, dosing schedule, and quantity of the medication. Next, you are asked if the patient has used this treatment before; select yes or no. If yes, enter the date when the patient started this treatment. You must also give your medical reasoning behind prescribing this treatment to your patient and list other medications they will use in combination with this treatment.

Step 9 – Section 9 asks for any previous services/therapy the patient has been prescribed and the dates discontinued for each treatment.

Step 10 – A signature is required at the bottom of the page as well as the current date.