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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.

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 1-855-599-3811.

Enrollee’s Information

Enrollee’s Contact Information

Requestor’s Contact Information

Pharmacy Information

Prescription Drug Information ?

Prescriber’s Information

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Last Updated On: 8/31/2017