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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 31397
Tampa, FL 33631

 1-866-388-1767


You may also ask us for a coverage determination by phone at 1-888-550-5252.

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

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Last Updated On: 8/31/2016
The Governor has declared a State of Emergency in Los Angeles County, due to the ongoing wild fires. If you are an affected member and need access to medical or pharmacy services, please call Member Services at 1-866-999-3945 for assistance. ×