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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, WellCare, 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 Action. This form may be sent to us by mail or fax:

Address
Fax Number

WellCare Health Plans
P.O. Box 31398
Tampa, FL 33631

1-888-865-6531

Expedited appeal requests can be made by phone at 1-866-800-6111.

Enrollee’s Information

Enrollee’s Contact Information

Requestor’s Contact Information

Prescription Drug Information ?

Prescriber’s Information

Print Form
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Last Updated On: 5/23/2016