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Coverage Determination Request

You may request a coverage decision and/or exception any of the following ways:
  
Electronic Prior Authorization (ePA): Cover My Meds
Online: Complete our online Request for Medicare Prescription Drug Coverage Determination.
FaxComplete a coverage determination request This PDF document will open in a new window. and fax it to 1-866-388-1767.
MailComplete a coverage determination request This PDF document will open in a new window. and send it to:

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

Injectable Infusion

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

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
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Last Updated On: 7/11/2022
Wellcare will be performing maintenance on Saturday, September 24th (from 6 P.M. EDT to 8 A.M. EDT the next day). You might not be able to access systems or fax during this time. We are sorry for any issues this may cause. Thank you for your patience. If you need assistance, contact us.
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