Submitting Successful Authorization Request

Date: 05/08/23

The fastest and most efficient way to request an authorization is through Wellcare’s secure Provider Portal.

However, requests for an authorization can also be submitted via fax or phone (emergent or urgent auths only).
The following information is generally required for all authorizations:

Member name
Member ID number
Provider ID and National Provider Identifier (NPI) number or name of the treating physician
Facility ID and NPI number or name where services will be rendered (when appropriate)
Provider and/or facility fax number
Date(s) of service
Diagnosis and diagnostic codes
CPT codes

Did You Know?
Providers may submit a Prior Authorization request on behalf of a member for brand name overrides and non-formulary medications. Prior Authorization requests are reviewed based on medical necessity.

The following supporting clinical documentation should be submitted:

Indication or diagnosis (ICD-10 code);Clinical notes and labs;
Trial and failure of at least two formulary agents, each used for at least 30 days unless contraindicated or
clinically significant adverse effects are experienced;
For brand name drugs, at least one previously tried agent was a generic version of the brand name drug and, if biosimilar is available, failure to all preferred biosimilars unless contraindications exist to the excipients in all generics/biosimilars;
Dose does not exceed the FDA approved maximum dose for the relevant indication and plan approved daily quantity limit or is supported by practice guidelines or peer-reviewed literature (submit supporting evidence);
Statement of medical necessity/reason why the member requires the requested medication.

Please check the online Provider Section of the member’s plan website for more information including how to submit
a Prior Authorization request.