Chuyển đến nội dung chính

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

1-866-388-1767


You may also Contact Us for a coverage determination.


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

Liên H Vi Chúng Tôi

Cần trợ giúp? Chúng tôi luôn sẵn sàng hỗ trợ.

Liên Hệ Với Chúng Tôi
Được Cập Nhật Lần Cuối Vào: 32/1/2020
Medicare Members: Your materials are on the way! We realize you may be waiting to receive some plan materials and we apologize for any delays. Did you know you can go online to our member portal to view Member materials, review your benefits, request or download an ID card, or choose a physician (when applicable)? Log in or register today!
×