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Coverage Determination Appeal

Providers may request a redetermination by submitting an appeal with supporting documentation.

You may file an appeal of a drug coverage decision any of the following ways:

Online: Complete our online Request for Redetermination of Medicare Prescription Drug Denial (Appeal).
Call: Refer to your Medicare Quick Reference Guide (QRG) for the appropriate phone number. 
Fax: Complete an Appeal of Coverage Determination Request (PDF) and fax it to 1-866-388-1766
Mail: Complete an Appeal of Coverage Determination Request (PDF) and send it to: 

Wellcare, Pharmacy Appeals Department
P.O. Box 31383
Tampa, FL 33631-3383

Basis for Requests

Providers may request coverage or exception for the following:

  • 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 (PDF)
  • 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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Y0020_WCM_100876E Last Updated On: 10/1/2022
Wellcare will be performing maintenance on Saturday, April 20th, from 6 P.M. EDT to 8 A.M. EDT the next day. You might not be able to access systems or fax during this time. We are sorry for any issues this may cause. Thank you for your patience. If you need assistance, contact us.
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