Medicare Request Appeal for Drug Coverage

Quién puede hacer solicitudes

Your prescriber may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. Contact us to learn how to name a representative.

Because we, WellCare, denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination. Puede enviarnos este formulario por correo postal o por fax:

Address	Número de fax
WellCare Health Plans P.O. Box 31383 Tampa, FL 33631	1-866-388-1766

You may also Contact Us for a coverage determination.

Enrollee's Information

First Name

Last Name

ID Number

Date of Birth

Información de contacto del afiliado

Dirección de correo electrónico

Phone Number

Street Address

Zip Code

City

State

Requestor's Contact Information

Complete la sección a continuación SOLO si la persona que realiza esta solicitud no es el afiliado:

First Name

Last Name

Relationship to Enrollee

Phone Number

Street Address

Zip Code

City

State

Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent) and enter a brief explanation below.

Prescription Drug Information

Name of Drug and Strength

Quantity Requested per Month

Dose

Check if you purchased the drug pending appeal

If "Yes":

Date Purchased

Amount Paid & Attach Receipt

Pharmacy Name

Pharmacy Phone Number

Información del médico prescriptor

First Name

Last Name

Street Address

Zip Code

City

State

Phone Number

Fax Number

Expedited Decision If you or your prescriber believe that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 7 days could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your prescriber's support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 72 HOURS.
If you have a supporting statement from your prescriber, attach it to this request.

Please explain your reasons for appealing. Enter any additional information you believe may help your case, such as a statement from your prescriber and relevant medical records. You may want to refer to the explanation we provided in the Notice of Denial of Medicare Prescription Drug Coverage.

Signature of person requesting the appeal (the enrollee, the enrollee's prescriber, or representative) and date are required upon submission.

Signature

Date

Imprimir formulario

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Última actualización: 8/31/2016

Medicare Request Appeal for Drug Coverage

Quién puede hacer solicitudes

Corrija los errores indicados a continuación:

Corrija los errores indicados a continuación

Enrollee's Information

Información de contacto del afiliado

Requestor's Contact Information

Prescription Drug Information

Información del médico prescriptor

¿Necesita ayuda? Puede contar con nosotros.

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Medicare Request Appeal for Drug Coverage

Quién puede hacer solicitudes

Corrija los errores indicados a continuación:

Corrija los errores indicados a continuación

Enrollee's Information ?

Información de contacto del afiliado

Requestor's Contact Information ?

Prescription Drug Information

Información del médico prescriptor

¿Necesita ayuda? Puede contar con nosotros.

Enrollee's Information

Requestor's Contact Information