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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 31383
Tampa, FL 33631
 1-888-877-8239

You may also Contact Us for a coverage determination.

Enrollee’s Information

Enrollee’s Contact Information

Requestor’s Contact Information

Prescription Drug Requested

Prescriber’s Information

Diagnosis and Medical Information

Rationale for Request

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Y0020_WCM_134133E_M Last Updated On: 10/1/2023
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