Skip to main content

Who May Make a Request

Your prescriber may ask us for a coverage determination on your behalf.  If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative.  Contact us to learn how to name a representative.

This form may be sent to us by mail or fax:

Fax Number 

Today's Options

P.O. Box 31397

Tampa, FL 33631


You may also ask us for a coverage determination by phone at:

Health Plan
Phone Number 

Today’s Options HMO

Today's Options PFFS

Today's Options PPO




Enrollee's Information ?

Enrollee's Contact Information

Requestor's Contact Information ?

Prescription Drug Requested

Type of Coverage Determination Request

Supporting Information for an Exception Request or Prior Authorization ?

Prescriber's Information

Diagnosis and Medical Information

Rationale for Request

Print Form

Need help? We're here for you.

Contact Us
Last Updated On: 11/27/2017