WellCare Health Plans, Inc : Determination Request : Redetermination

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Request for Redetermination of Medicare Prescription Drug Denial

Because we, WellCare, denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a 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. This form may be sent to us by mail or fax:

Address:
WellCare Health Plans
P.O.Box 31383
Tampa, FL 33631

Fax Number:
1-866-388-1766

You may also ask us for an appeal through our website at www.wellcare.com. Expedited appeal requests can be made by phone at 1-866-800-6111.

Who May Make a Request:

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.

* Indicates a required field

Enrollee's Information

Enrollee's Information
Enrollee's First Name *	Enrollee's Last Name *	Date of Birth *

Enrollee's Information
Enrollee's Address

Enrollee's Information
City	State	Zip Code

Enrollee's Information
Phone

Enrollee's Information
Enrollee's Plan ID Number *

Complete the following section ONLY if the person making this request is not the enrollee:

Requestor's Information
Requestor's First Name	Requestor's Last Name

Requestor's Information
Requestor's Relationship to Enrollee

Requestor's Information
Address

Requestor's Information
City	State	Zip Code

Enrollee's Information
Phone

Representation documentation for appeal requests made by someone other than enrollee or the enrollee's prescriber:

Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent) if it was not submitted at the coverage determination level. For more information on appointing a representative, contact your plan or 1-800-Medicare.

Prescription drug you are requesting

Prescription Information
Name of drug and Strength: *
Quantity: *
Dose:
Have you purchased the drug pending appeal?

Prescription Information
If "Yes": Date Purchased:		Amount paid:	$ (attach copy of receipt below)

Prescription Information
Name and telephone number of pharmacy:

Prescriber's Information

Prescribing Physician Information
Name *

Prescribing Physician Information
Address

Prescribing Physician Information
City	State	Zip Code

Prescribing Physician Information
Office Phone	Fax *

Prescribing Physician Information
Office Contact Person *

Important Note: Expedited Decisions

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. Attach additional pages, if necessary. Attach 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.

(Required)

Up to 10 individual files can be attached.
Attached files cannot exceed a total size of 100.0 MB.

Attachment 1:

Attachment 2:

Attachment 3:

Add more Attachments Remove

Signature of person requesting the appeal (the enrollee, or the enrollee's prescriber or representative):*

Date:

Y0070_NA018009_WCM_WEB_ENG CMS Approved 03262012

Last Modified: 03/26/2012