Medical Drug Authorization Request
Drug Prior Authorization Requests Supplied by the Physician/Facility
Instructions: To ensure our members receive quality care, appropriate claims payment, and notification of
servicing providers, please complete this form in its entirety. Fax completed form to 1-888-871-0564.
By using this form, the physician (or prescriber) is asking for Medical/Part B drug coverage meeting one or
both criteria:
1. The drug is being supplied and administered in the physician’s office. Provider will bill the health plan directly.
2. The drug is being supplied and administered at a facility or outpatient center. Facility/outpatient center will bill the
health plan directly.
Who is making this request? Provider Member Appointed Representative
Appointed Representatives: Please include a signed Appointment of Representative form (CMS-1696) or equivalent
notice.
Priority Level
Expedited
Standard
Post-service
Appointed Representative
Complete the following section ONLY if the person making this request is not the member or prescriber:
Requestor’s Name:
Requestor’s Relationship to Member:
Address, City, State, ZIP:
Requestor’s Phone:
Member
Member Name:
Member ID#:
Member Address, City, State, ZIP:
Phone:
DOB:
Ht/Wt (lb/kg):
Allergies:
ICD-10:
Requesting Provider
Wellcare ID Number:
NPI Number:
PRO_43122E Internal Approved 08262019
©Wellcare 2022
NA9PROFRM43122E_0000
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Last Name:
First Name:
Street Address:
City, State:
ZIP:
Phone Number
Fax Number:
Provider Type/Specialty:
Name of Requestor:
Treating Provider/Vendor
Out of Network If Yes, Please Provide Reason:
Wellcare ID Number:
NPI Number:
Last Name:
First Name:
Street Address:
City, State:
ZIP:
Phone Number
Fax Number:
Provider Type/Specialty:
Name of Requestor:
Facility Information
Type:
Office OP H ospital Home-Infusion/DME P rovider
Tax ID:
Wellcare ID Number:
NPI Number:
Facility Name:
Phone Number:
Fax Number:
Street Address:
City, State:
ZIP:
Medication/Service Requested
Medication/HCPCS Code (s)
Dose
Visits/Frequency
Length of Treatment
(Please use another form if more lines are needed.) Physician Signature:
Document clinical rationale for override/exception request. List names and doses of previous medication(s) tried and
failed. Fax all supporting documentation.
PRO_43122E Internal Approved 08262019 NA9PROFRM43122E_0000
©Wellcare 2022
