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Who May Make a Request

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

Because we, Staywell, denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for redetermination (appeal) of our decision. You may ask for a redetermination after the date of our Notice of Adverse Benefit Determination. This form may be sent to us by mail or fax:

Fax Number

Staywell Health Plan
Attn: Appeals Department
P.O. Box 31398
Tampa, FL 33631


Expedited appeal requests can be made by phone at 1-866-800-6111. If you need help, please call Customer Service. You can reach them at 1-866-334-7927 (TTY 1-877-247-6272).

Enrollee’s Information

Enrollee’s Contact Information

Requestor’s Contact Information

Prescription Drug Information ?

Prescriber’s Information

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Last Updated On: 12/4/2020
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