Skip to main content

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
 1-855-620-1868

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

Print Form
Contact Us icon

Need help? We're here for you.

Contact Us
Y0020_WCM_134133E_M Last Updated On: 10/1/2023