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Medicare Advantage and Dual Advantage
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.
WellCare Health Plans Pharmacy - Coverage Determinations P.O. Box 31397 Tampa, FL 33631-3397
Fax: 1-844-235-5021
By phone:
1-800-247-1447 TTY: 711