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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:

Address  Fax Number
 WellCare Health Plans
P.O. Box 31383
Tampa, FL 33631
 1-800-678-3189

You may also Contact Us for a coverage determination. 

Enrollee’s Information

Enrollee’s Contact Information

Requestor’s Contact Information

Prescription Drug Requested

Prescriber’s Information

Diagnosis and Medical Information

Rationale for Request

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Y0020_WCM_134133E_M Last Updated On: 10/1/2023
On April 22, 2024, UnitedHealth Group issued a press release, providing an update on the Change Healthcare cybersecurity incident that occurred on Feb. 21, 2024. Given the size of the data impacted, the investigation to determine whose data is impacted is expected to take several months. UnitedHealth Group believes this situation will impact “a substantial proportion of people in America” and is offering immediate credit monitoring and identity protection services, as well as a dedicated contact center to address questions. Visit Change Healthcare Cyberattack Support and/or reach out to the contact center at 1-866-262-5342 regarding any questions.

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