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Coverage Determination Request

You may request a coverage decision and/or exception any of the following ways:  

WellCare, Pharmacy-Coverage Determinations
P.O. Box 31397
Tampa, FL 33631-3397

For overnight requests:
WellCare, Pharmacy-Coverage Determinations
8735 Henderson Road, Ren. 4
Tampa, FL 33634

For injectable infusion coverage determination requests, please use the WellCare Injectable Infusion form This PDF document will open in a new window..

Basis for Requests
Providers may request an addition or exception for the following:

  • 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

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.

Basis for Requests
Providers may request an addition or exception for the following:

  • 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

For injectable infusion coverage determination requests, please use this form:

  • Basis for Requests

    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.

    Basis for Requests
    Providers may request an addition or exception for the following:

    • 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

    For injectable infusion coverage determination requests, please use this form:

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Last Updated On: 7/15/2019