Ir al contenido principal

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
Ícono de contacto

¿Necesita ayuda? Puede contar con nosotros.

Contáctenos
Última actualización: 5/17/2023
On Feb. 21, 2024, Change Healthcare experienced a cyber security incident. Any individuals impacted by this incident will receive a letter in the mail. Learn more about this from Change Healthcare, or reach out to the contact center at at 1-866-262-5342.

×