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
