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Coverage Determination Request

Providers may request a coverage decision and/or exception any of the following ways:

Electronic Prior Authorization (ePA): Cover My Meds
Online: Complete our online Request for Medicare Prescription Drug Coverage Determination form.
Fax: Complete a Coverage Determination Request (PDF) and fax it to 1-866-388-1767.
Mail: Complete a Coverage Determination Request (PDF) and send it to:

Wellcare, Pharmacy-Coverage Determinations
P.O. Box 31397
Tampa, FL 33631-3397

For Overnight Requests:

Wellcare, Pharmacy-Coverage Determinations
8735 Henderson Road, Ren. 4
Tampa, FL 33634

Injectable Infusion

For coverage determination requests, please use the Wellcare Injectable Infusion form (PDF)

Basis for Requests

This process ensures that medication regimens that are high risk, have a high potential for misuse or have narrow therapeutic indices are used appropriately and according to FDA-approved indications. Providers may request an addition or exception for:

  • Drugs not listed in the Formulary
  • Duplication of therapy
  • Prescriptions that exceed the FDA daily or monthly quantity limit
  • Most self-injectable and infusion medications
  • Drugs that have an age edit
  • Drugs listed on the PDL but still requiring Prior Authorization (PA)
  • Brand name drugs when a generic exists
  • Drugs that have a step edit (ST) and the first-line therapy is inappropriate
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Last Updated On: 5/16/2023