You must be 18 years of age or older to order an Over the Counter (OTC) items. If you are under 18 years old, please contact customer service. Are you 18 years of age or older?
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:
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
Complete the following section ONLY if the person making this request is not the enrollee:
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
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.
Signature of person requesting the appeal (the enrollee, or the enrollee's prescriber or representative):*
Y0070_NA023899_WCM_WEB_ENG CMS Approved
Last modified: 01/01/2014
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