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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

1-855-620-1868

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

Print Form
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Last Updated On: 5/17/2018
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