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management rules. WellCare will ... Information on this form is protected health information and subject to all privacy

Rev. 05/10

Coverage Determination Request Form - Florida 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 applicable medical criteria, FDA guidelines, protocols developed by the WellCare Pharmacy & Therapeutics Committee, and plan benefits. Who is making this request?

Provider

Member

Appointed Representative

Appointed Representatives: Please include a signed Appointment of Representative form (CMS-1696) or equivalent notice. Please Check One (Not checking a box will indicate a Standard review) REQUEST FOR STANDARD REVIEW (72 HOURS) REQUEST FOR EXPEDITED REVIEW (24 HOURS) By checking the expedited box, the requestor certifies that applying the 72 hour standard review time frame may seriously jeopardize the life or health of the member or the member’s ability to regain maximum function.

Complete each section legibly and completely (include any additional necessary medical records) Member Name

____________________________________________

WellCare ID #

State:

________________

________________

Date of Birth

Date of Request ________________ Physician Name

____________________________________________

Pt currently in LTC? Yes or No Member’s Telephone Number

Physician Signature

Diagnosis of Requested Medication

Sent by

Medication Requested (list only one medication and strength per form)

Physician Phone #

Dose

Dosage Form

Physician Fax #

Directions for Use

Quantity

Pharmacy Phone #

________________

____________________________________________

Specialty

____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ________________

________________

________________

________________

Duration of Therapy

________________

________________ ________________

Pharmacy Fax #

____________________________________________ ________________

Document clinical rationale for override/exception request. List all names and doses of previous medication(s) tried and failed. Fax all supporting documentation. ________________________________________________________________________________________ ________________________________________________________________________________________

FAX to WellCare Pharmacy Department at 1-866-388-1767 Information on this form is protected health information and subject to all privacy and security regulations under HIPAA.