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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 31397
Tampa, FL 33631
 1-866-388-1766

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

Enrollee's Information ?

Enrollee's Contact Information

Requestor's Contact Information ?

Prescription Drug Requested

Type of Coverage Determination Request

Supporting Information for an Exception Request or Prior Authorization ?

Prescriber's Information

Diagnosis and Medical Information

Rationale for Request

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Awagandakami
Last Updated On: 5/23/2016
Dagiti Miembro ti Medicare: Saluadan ti bagim maipanggep iti panagkusit ken panagtakaw iti identidad iti Medicare Ipabpablaak ti Departamento ti Salun-at ken Opisina ti Pagalagadan ti Tao ti Inspektor Heneral iti U.S. ti wagas ti panagkusit a manginaig ti genetic a panageksamen. Adalen no kasano a saluadan ti bagim.
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