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Coverage Determination Request

You may request a coverage decision and/or exception any of the following ways:
  
- Electronic Prior Authorization (ePA): Surescripts Prior Authorization Portal
- Online: Request Prescription Drug Coverage using our online form.
- FaxComplete a coverage determination request This PDF document will open in a new window. and fax it to 1-866-388-1767.
- MailComplete a coverage determination request This PDF document will open in a new window. and send it to:

WellCare, Pharmacy-Coverage Determinations
P.O. Box 31397
Tampa, FL 33631-3397

For Overnight Requests:

WellCare, Pharmacy-Coverage Determinations
8735 Henderson Road, Ren. 4
Tampa, FL 33634

- Call: Refer to your Medicare Quick Reference Guide This PDF document will open in a new window. for the appropriate phone number.

Basis for Requests

This process ensures that medication regimens that are high risk, have a high potential for misuse or have narrow therapeutic indices are used appropriately and according to FDA-approved indications. Providers may request an addition or exception for:

  • Drugs not listed in the Formulary
  • Duplication of therapy
  • Prescriptions that exceed the FDA daily or monthly quantity limit
  • Most self-injectable and infusion medications 
  • Drugs that have an age edit
  • Drugs listed on the PDL but still requiring Prior Authorization (PA)
  • Brand name drugs when a generic exists
  • Drugs that have a step edit (ST) and the first-line therapy is inappropriate
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Last Updated On: 9/3/2019