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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 31397
Tampa, FL 33631
 1-866-388-1766

You may also ask us for a coverage determination by phone at 1-888-550-5252.

Enrollee's Information ?

Enrollee's Contact Information

Requestor's Contact Information ?

Prescription Drug Requested

Type of Coverage Determination Request

Supporting Information for an Exception Request or Prior Authorization ?

Prescriber's Information

Diagnosis and Medical Information

Rationale for Request

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Last Updated On: 5/23/2016
WellCare will be performing maintenance on Saturday, May 21 (from 6 PM EDT to 8 AM EDT the next day). You might not be able to access systems or fax during this time. We are sorry for any issues this may cause. Thank you for your patience. If you need assistance, contact us.
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