Medicare Providers

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.
• 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

For Overnight Requests:

WellCare, Pharmacy-Coverage Determinations
8735 Henderson Road, Ren. 4
Tampa, FL 33634

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

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