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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).

Fax: Complete an appeal of coverage determination request Tài liệu PDF này sẽ mở trong cửa sổ mới. and fax it to 1-866-388-1766.
Mail: Complete an appeal of coverage determination request Tài liệu PDF này sẽ mở trong cửa sổ mới. and send it to: 

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

Call: Refer to your Medicare Quick Reference Guide Tài liệu PDF này sẽ mở trong cửa sổ mới. for the appropriate phone number.

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 
  • 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: 9/3/2019