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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.

You may also ask us for a coverage determination by phone at 1-888-550-5252.

  • Printable Form: Request for Medicare Prescription Drug Determination (PDF).
    This form may be sent to us by mail or fax:
    • Mail:
      • Wellcare Health Plans P.O. Box 31397 Tampa, FL 33631
    • Fax:
      • Wellcare Medicare Advantage Plans:
        • 1-866-388-1767 – Non-CA Plans
        • 1-877-277-1809 – CA Plans
      • Wellcare Prescription Drug Plans (PDP)
        • 1-866-388-1767

Enrollee's Information ?

Enrollee's Contact Information

Requestor's Contact Information ?

Medicamento recetado solicitado

Type of Coverage Determination Request

Supporting Information for an Exception Request or Prior Authorization ?

Prescriber's Information

Información médica y de diagnóstico

Motivo de la solicitud

Ícono de Contact Us (Comuníquese con nosotros)

¿Necesita ayuda? Puede contar con nosotros.

Comuníquese con nosotros
Y0020_WCM_164006E_M Last Updated On: 10/1/2024
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