Skip to main content

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

1-888-877-8239

You may also Contact Us for a coverage determination.

Enrollee’s Information

Enrollee’s Contact Information

Requestor’s Contact Information

Prescription Drug Requested

Important Notes: Expedited Decision

Prescriber’s Information

Diagnosis and Medical Information

Rationale for Request

Print Form
contact-us

Need help? We're here for you.

Contact Us
Last Updated On: 5/23/2016
On September 1, 2018, our premium payment services changed. These changes will make it easier for you to pay your premium. Read more. ×
‘Ohana Health Plan is committed to helping members and providers who have been affected by recent events. Read more. ×