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Medicare Advantage and Dual Advantage
The purpose of this form is to request coverage of a medication that is not on your plan’s drug list or restricted in some way. Completion of this form provides information for the plan to decide whether to waive the restriction for you. We may or may not agree to waive the restriction for you. Members who complete this form may need clinical information, which can be provided by your medical prescriber.
Wellcare By Fidelis CareAttention: Pharmacy Services DepartmentPO Box 9525 Amherst, NY 14226
Fax: 877-882-5892
By phone:
1-800-247-1447 TTY: 771