Skip to main content


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.

Request for Medicare Prescription Drug Determination (PDF) This form may be sent to us by mail or fax:

 Address Fax Number
 Wellcare Health Plans
P.O. Box 31397
Tampa, FL 33631
 1-866-388-1767

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

Print Form
Contact Us icon

ᎤᏚᎸᏓ ᎠᏍᏕᎸᏗᎢ? ᎠᎭᏂ ᎣᏤᏙ ᏂᎯ ᏳᏰᎵᏗ.

ᎢᏍᎩᏟᏃᎮᏓ ᏂᎦᏓ
Y0020_WCM_134133E_M Last Updated On: 10/1/2023
On April 22, 2024, UnitedHealth Group issued a press release, providing an update on the Change Healthcare cybersecurity incident that occurred on Feb. 21, 2024. Given the size of the data impacted, the investigation to determine whose data is impacted is expected to take several months. UnitedHealth Group believes this situation will impact “a substantial proportion of people in America” and is offering immediate credit monitoring and identity protection services, as well as a dedicated contact center to address questions. Visit Change Healthcare Cyberattack Support and/or reach out to the contact center at 1-866-262-5342 regarding any questions.

×