Prior Authorization Requirements

Wellcare By Health Net Medicare Advantage

Effective January 1, 2024

The services, procedures, equipment and outpatient pharmaceutics below apply to:

  • Wellcare By Health Net Medicare Advantage (MA) PPO and HMO Direct Network1

These are subject to prior authorization (PA) requirements (unless noted as “notification” required only) and guaranteed only as of the time of access to this prior authorization requirements page. Providers are responsible for verifying member eligibility through the Provider Services prior to providing care. Even if a service or supply is authorized, eligibility rules and benefit limitations will still apply.

This PA list is not intended to be a list of covered services. The member’s Evidence of Coverage (EOC) provides a complete list of covered services. EOCs are available to members on the member portal at or in hard copy on request. Providers may obtain a copy of a member’s EOC by requesting it from Provider Services.

Submit a prior authorization request to Wellcare By Health Net unless stated differently in the requirements listed below. Requests should be submitted to Health Net via fax. The Health Net Request for Prior Authorization form must be completed in its entirety and include sufficient clinical information or notes to support medical necessity for services that are requested.

When faxing a request, please attach pertinent medical records, treatment plans, test results, and evidence of conservative treatment to support the medical appropriateness of the request. All services are subject to benefit plan coverage limitations, members must be eligible, and medical necessity must exist for any plan benefit to be a covered service irrespective of whether or not PA is required.

Confirm whether a specific code requires authorization on the Medicare Pre-Auth page.

Log in to submit a prior authorization request. 

For MA PPO plans, PA is recommended, but not required, for out-of-network coverage only.

If members have questions regarding the PA list or requirements, refer to the member services number listed on their identification card.

1 Direct Network refers to the directly contracted network.