Wellmed prior authorization form 2026

1. Click ‘Get Form’ to open the wellmed prior authorization form in the editor.
2. Begin by entering the Member ID# and Date Submitted at the top of the form. Ensure accuracy as this information is crucial for processing.
3. Fill in your Name, DEA#, Phone, NPI #, and Diagnosis (Dx). These fields are essential for identifying the prescriber and patient details.
4. Select the Drug Requested by checking the appropriate box. Specify the Quantity and Sig (instructions) clearly to avoid any confusion.
5. Complete the Primary Diagnosis section with ICD-9 code and provide details about psychosocial counseling, including compliance status.
6. Answer questions regarding alcohol abuse and opioid use history. Provide clinical reasons if requesting doses above standard limits.
7. Ensure to attach a current urine drug screen as required before submission.
8. Finally, sign and date the form at the bottom. Once completed, fax it to WellCare Pharmacy using the provided number.

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