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Request for Prescription Drug Coverage Determination

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.


Mail, Fax, or Call

WellCare Health Plans Pharmacy - Coverage Determinations 
P.O. Box 31397 
Tampa, FL 33631-3397

Fax: 1-844-235-5021

By phone:

TTY: 711