주요 콘텐츠로 건너뛰기


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 Determination이 PDF 문서는 새로운 창에서 열립니다. 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

양식 인쇄
연락처 아이콘

도움이 필요하세요? 기꺼이 도와드리겠습니다.

연락 정보
최근 업데이트 날짜: 2020/12/04