Prior Authorization Rules for Medical Benefits

What services require Prior Authorization?

To obtain a list of services that require prior authorization, please contact Member Services. Please note out-of-network/non- contracted providers are under no obligation to treat Wellcare members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost- sharing that applies to out-of-network services

What is the process for obtaining a Prior Authorization?

You may request prior authorization by contacting Member Services. We recommend that providers submit prior authorizations through the web portal, via phone or via fax.

Decisions and notifications will be made no later than 72 hours after receipt for requests meeting the definition of Expedited (fast decision) and no later than 14 calendar days for requests meeting the definition for Standard. Wellcare automatically expedites an organization determination if we find that your health, life, or ability to regain maximum function may be jeopardized by waiting for a standard determination. We will notify you of our decision either in writing or via telephone. In the case of an emergency, you do not need prior authorization.

Prior authorization is not a guarantee of payment. Wellcare retains the right to review the medical necessity of services, eligibility for services, and benefit limitations and exclusions after you receive the services.

Pharmacy Prior Authorization

Looking for Drug Coverage Determinations - Exceptions and Prior Authorizations? Visit the Coverage Determinations for Drugs - Exceptions and Prior Authorizations page.