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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

1-866-825-2884

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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Last Updated On: 5/23/2016
Medicare and Prescription Drug Plan Members: A new and enhanced member portal will soon be available. This portal will offer a fresh homepage, all new billing and payment options for 2020, and more! Check back on 10/15 to see what else is new. ×