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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:

 Fax Number

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


You may also Contact Us for a coverage determination.

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: 11/16/2018
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