Get Injectable Infusion Form 2010-2024

WELLCARE INJECTABLE INFUSION FORM Coverage Determination Request for WellCare of Florida Staywell and HealthEase FAX to 1-866-825-2884 WellCare Pharmacy - Injectable Infusion Department 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 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 or laboratory results. Member Name Member Address City State Zip Phone Ht/Wt lb/kg Allergies Medication DOB Dx ICD9 Dose Provider Name Provider Address Provider Phone Provider Contact Name Provider ID / NPI Frequency Date of Request 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* Please answer all questions below for a thorough review. 1. Is the medication being administered in physician s office Yes see A B below No A. Will the medication be sent to the provider s office for administration Yes No If Yes Pharmacy is responsible for collecting the medication co-payment from the patient. B. Will physician supply medication Yes If Yes Physician s office is responsible for collecting medication co-payment from the patient. Facility/Outpatient Clinic Name Facility/Clinic Provider ID Information on this form is protected health information and subject to all privacy and security regulations under HIPAA. Who is making this request Provider Member 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 or laboratory results. 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 or laboratory results. Member Name Member Address City State Zip Phone Ht/Wt lb/kg Allergies Medication DOB Dx ICD9 Dose Provider Name Provider Address Provider Phone Provider Contact Name Provider ID / NPI Frequency Date of Request Length of Treatment Please use another form if more lines are needed Physician Signature Document clinical rationale for override/exception request. .