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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 31398
Tampa, FL 33631

1-877-276-9630

You may also Contact Us for a coverage determination.

Enrollee’s Information

Enrollee’s Contact Information

Requestor’s Contact Information

Pharmacy Information

Prescription Drug Requested

Important Notes: Expedited Decision

Prescriber’s Information

Diagnosis and Medical Information

Rationale for Request

Print Form
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Last Updated On: 3/15/2017
On September 1, 2018, our premium payment services changed. These changes will make it easier for you to pay your premium. Read more. ×