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 By Fidelis Care
Attention: Pharmacy Services Department
PO Box 9525 
Amherst, NY 14226

Fax: 877-882-5892

By phone:

TTY: 771