Coverage Decisions and Appeals
The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for prescription drugs, including problems related to payment. This is the process you use for issues such as whether something is covered or not and the way in which something is covered.
How to make an appeal?
To start your appeal, you, your doctor or your representative must contact our plan. If you are asking for a standard appeal, make your appeal by submitting a written request. If you are asking for a fast appeal, you may make your appeal in writing or you may call us. You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you of our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.
If your health requires it, ask for a "fast appeal." If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it. If we are using the standard deadlines, we must give you our answer within 7 calendar days after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so. If you believe your health requires it, you should ask for "fast" appeal.
There are four ways to file an appeal for Part D Determination:
- Complete our online Request for Redetermination of Medicare Prescription Drug Denial (Appeal) form, which can also be found on your plan's Pharmacy page.
- Fax: 1-866-388-1766
- Call Us: 1-800-633-4227
- Write: WellCare, Pharmacy Appeals Department, P.O. Box 31383, Tampa, FL 33631-3383
You may download the following form to use on your appeal:
Independent Review Organizations; also known as Independent Review Entity (IRE)
If our plan says no to your appeal, you then can choose whether to accept this decision or continue making another appeal. If you decide to go on to a Level 2 appeal, the Independent Review Organization reviews the decision our plan made when we said no to your first appeal. This organization decides whether the decision we made should be changed. The Independent Review Organization an independent organization that is hired by Medicare.