[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-283813-105":53,"doc-detail-283813-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","medical-drug-authorization-request-complete-the-form-and-fax-supporting-documents","Medical Drug Authorization Request - Complete the Form and Fax Supporting Documents","","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.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/medical-drug-authorization-request-complete-the-form-and-fax-supporting-documents/283813/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/medical-drug-authorization-request-complete-the-form-and-fax-supporting-documents/283813.png","ImageObject",442,249,{"name":88,"@type":89},"Theodore","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-11-01","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Who is eligible to make a Medical Drug Authorization Request on this form?","Question",{"text":109,"@type":110},"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.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"When should a physician use this form for drug coverage?",{"text":114,"@type":110},"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).",{"name":116,"@type":107,"acceptedAnswer":117},"What supporting information must be included with the request?",{"text":118,"@type":110},"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.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},283813,1789620206,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":126,"read_time":9},7971461740886,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","Medical Drug Authorization Request  \nDrug Prior Authorization Requests Supplied by the Physician/Facility  \nInstructions: 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.  \nBy using this form, the physician (or prescriber) is asking for Medical/Part B drug coverage meeting one or both criteria:  \n1. The drug is being supplied and administered in the physician’s office. Provider will bill the health plan directly.  \n2. The drug is being supplied and administered at a facility or outpatient center. Facility/outpatient center will bill the health plan directly.  \nWho is making this request?  Provider  Member  Appointed Representative  \nAppointed Representatives: Please include a signed Appointment of Representative form (CMS-1696) or equivalent notice.  \n\n| Priority Level |  |  |  |  |\n| --- | --- | --- | --- | --- |\n|  Expedited  Standard  Post-service |  |  |  |  |\n| Appointed Representative\u003Cbr>Complete the following section ONLY if the person making this request is not the member or prescriber: |  |  |  |  |\n| Requestor’s Name: |  |  |  | Requestor’s Relationship to Member: |\n| Address, City, State, ZIP: |  |  |  |  |\n| Requestor’s Phone: |  |  |  |  |\n| Member |  |  |  |  |\n| Member Name: |  |  | Member ID\\#: |  |\n| Member Address, City, State, ZIP: |  |  |  |  |\n| Phone: |  | DOB: |  |  |\n| Ht/Wt (lb/kg): | Allergies: |  |  | ICD-10: |\n| Requesting Provider |  |  |  |  |\n| Wellcare ID Number: |  | NPI Number: |  |  |\n\nPRO_ 43122E Internal Approved 08262019 NA9PROFRM43122E_0000  \n©Wellcare 2022  \n| Last Name: |  |  |  |  |  |  |  | First Name: |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Street Address: |  |  |  |  |  |  |  | City, State: |  | ZIP: |  |  |  |\n| Phone Number |  |  |  |  |  |  |  | Fax Number: |  |  |  |  |  |\n| Provider Type/Specialty: |  |  |  |  |  |  |  | Name of Requestor: |  |  |  |  |  |\n| Treating Provider/Vendor |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  Out of Network If Yes, Please Provide Reason: |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Wellcare ID Number: |  |  |  |  |  |  |  | NPI Number: |  |  |  |  |  |\n| Last Name: |  |  |  |  |  |  |  | First Name: |  |  |  |  |  |\n| Street Address: |  |  |  |  |  |  |  | City, State: |  |  |  | ZIP: |  |\n| Phone Number |  |  |  |  |  |  |  | Fax Number: |  |  |  |  |  |\n| Provider Type/Specialty: |  |  |  |  |  |  |  | Name of Requestor: |  |  |  |  |  |\n| Facility Information |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Type: |  | Office |  | OP Hospital |  |  | Home-Infusion/DME Provider |  | Tax ID: |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Wellcare ID Number: |  |  |  |  |  |  |  | NPI Number: |  |  |  |  |  |\n| Facility Name: |  |  |  |  |  |  |  | Phone Number: |  |  | Fax Number: |  |  |\n| Street Address: |  |  |  |  |  |  |  | City, State: |  |  | ZIP: |  |  |\n| Medication/Service Requested |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Medication/HCPCS Code (s) |  |  |  |  | Dose |  |  |  | Visits/Frequency |  |  |  | Length of Treatment |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n\n(Please use another form if more lines are needed.) Physician Signature:  \nDocument clinical rationale for override/exception request. List names and doses of previous medication(s) tried and failed. Fax all supporting documentation.  \n____________________________________________________________________________________________  \n____________________________________________________________________________________________  \nPRO_ 43122E Internal Approved 08262019 NA9PROFRM43122E_0000  \n©Wellcare 2022","cbCaisBkz7HboOJn","https://ap.wps.com/l/cbCaisBkz7HboOJn","pdf",764062,"English","# Medical Drug Authorization Request\n## Prior Authorization Criteria\n## Requestor and Appointed Representative Information\n## Member and Requesting Provider Details\n## Facility Information\n## Medication/Service Requested\n## Physician Signature and Supporting Documentation","[{\"question\":\"Who is eligible to make a Medical Drug Authorization Request on this form?\",\"answer\":\"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.\"},{\"question\":\"When should a physician use this form for drug coverage?\",\"answer\":\"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).\"},{\"question\":\"What supporting information must be included with the request?\",\"answer\":\"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.\"}]","Medical Drug Authorization Request - Complete the Form and Fax Supporting Documents | PDF"]