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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

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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



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Prescriber's Information


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.












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















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Y0070_NA023899_WCM_WEB_ENG CMS Approved


Last modified: 01/01/2014

 

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