Request a Coverage Decision
You may request a coverage decision and/or exception any of the following ways:
- Electronic Prior Authorization (ePA): Surescripts Prior Authorization Portal
- Online: Complete our online Request for Medicare Prescription Drug Coverage Determination.
- Fax: Complete a coverage determination request and fax it to 1-866-388-1767.
- Mail: Complete a coverage determination request and send it to:
WellCare, Pharmacy-Coverage Determinations
P.O. Box 31397
Tampa, FL 33631-3397
- Call: Refer to your Medicare Quick Reference Guide for the appropriate phone number.
Basis for Requests
This process ensures that medication regimens that are high risk, have a high potential for misuse or have narrow therapeutic indices are used appropriately and according to FDA-approved indications. Providers may request an addition or exception for:
- Drugs not listed in the Formulary
- Duplication of therapy
- Prescriptions that exceed the FDA daily or monthly quantity limit
- Most self-injectable and infusion medications
- Drugs that have an age edit
- Drugs listed on the PDL but still requiring Prior Authorization (PA)
- Brand name drugs when a generic exists
- Drugs that have a step edit (ST) and the first-line therapy is inappropriate