Medical Drug Authorization Request - Complete the Form and Fax Supporting Documents

Sep 17, 2026

Uploaded by Theodore

Medical Drug Authorization Request form for prior authorization of Medical/Part B drug coverage. Physicians (or prescribers) submit the request when drugs are administered in the physician’s office billed directly to the health plan, or when drugs are administered at a facility/outpatient center billed directly to the health plan. The form collects requestor, member, provider, and facility details, medication/HCPCS information, and includes an attestation section for appointed representatives when applicable. Supporting documentation must be faxed.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Medical Drug Authorization Request

Prior Authorization Criteria

Requestor and Appointed Representative Information

Member and Requesting Provider Details

Facility Information

Medication/Service Requested

Physician Signature and Supporting Documentation

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 NA9PROFRM43122E_0000 ©Wellcare 2022 | 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 Hospital | | | Home-Infusion/DME Provider | | 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

FAQs

Who is eligible to make a Medical Drug Authorization Request on this form?

The request can be made by the provider, the member, or an appointed representative. If the appointed representative is completing it, an Appointment of Representative form (CMS-1696) or equivalent notice is required.

When should a physician use this form for drug coverage?

Use it when requesting Medical/Part B drug coverage meeting one or both criteria: the drug is supplied and administered in the physician’s office (health plan billed directly), or supplied and administered at a facility/outpatient center (facility/outpatient center billed directly).

What supporting information must be included with the request?

The physician must provide clinical rationale for any override/exception request, list prior medication names and doses that were tried and failed, and fax all supporting documentation.

Sep 17, 2026

Uploaded by Theodore