You must be 18 years of age or older to order an Over the Counter (OTC) items. If you are under 18 years old, please contact customer service. Are you 18 years of age or older?
This form may be sent to us by mail or fax:
You may also ask us for a coverage determination by phone at 1-866-800-6111 or through our website at www.wellcare.com.
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.
* Indicates a required field
Complete the following section ONLY if the person making this request is not the enrollee or prescriber:
Representation documentation for requests made by someone other than enrollee or the enrollee's prescriber:
Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent). For more information on appointing a representative, contact your plan or 1-800-Medicare.
Type of Coverage Determination Request
(Please select at least one item from the list below.)
Additional information we should consider (attach any supporting documents):
If you or your prescriber believe that waiting 72 hours for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 72 hours could seriously harm your health, we will automatically give you a decision within 24 hours. If you do not obtain your prescriber's support for an expedited request, we will decide if your case requires a fast decision. You cannot request an expedited coverage determination if you are asking us to pay you back for a drug you already received.
Signature of person requesting the coverage determination (the enrollee, or the enrollee's prescriber or representative):*
Diagnosis and Medical Information
Rationale for Request ( Select all that apply ) *
Y0070_NA023899_WCM_WEB_ENG CMS Approved
Last modified: 01/01/2014
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