If a drug is not covered in the way you would like it to be covered, you can ask the plan to make an “exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.
When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception to be approved. We will then consider your request. Here are three examples of exceptions that you or your doctor or other prescriber can ask us to make:
- Covering a Part D drug for you that is not on our List of Covered Drugs (Formulary).
- Removing a restriction on our coverage for a covered drug. There are extra rules or restrictions that apply to certain drugs on our List of Covered Drugs (Formulary).
- Changing coverage of a drug to a lower cost-sharing tier. Every drug on the plan's Drug List is in one of the 4-cost-sharing tiers. In general, the lower the cost-sharing tier number, the less you will pay as your share of the cost of the drug. Drugs on tier 5 are not eligible for an exemption.
Requesting an expedited exception
If you or your prescriber believe that waiting 72 hours 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 72 hours could seriously harm your health, we will automatically give you a decision within 24 hours. If you do not obtain your prescriber's support for an expedited request, we will decide if your case requires a fast decision. You cannot request an expedited coverage determination if you are asking us to pay you back for a drug you already received.
Important things to know about asking for exceptions:
Your doctor must tell us the medical reasons.
Your doctor or other prescriber must give us a written exception that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception. If your doctor or prescriber does not include this information it could take longer than the 24-72 hours.
Typically our Drug List includes more than one drug for treating a particular condition. These different possibilities are called "alternative" drugs. If an alternative drug would be just as effective as the drug you are requesting and would not cause more side effects or other health problems, we will generally not approve your request for an exception.
You can ask for a coverage decision and/or exception by one of the four following ways:
- Complete our online Request for Medicare Prescription Drug Coverage Determination form, which can be found on your plan's Pharmacy page.
- Fax: 1-866-388-1767
- Call Us: Refer to the Customer Service number on the back of your member ID card.
- Write: WellCare, Pharmacy-Coverage Determinations, P.O. Box 31397, Tampa, FL 33631-3397
- Overnight Address: WellCare, Pharmacy-Coverage Determinations, 8735 Henderson Road, Ren. 4, Tampa, FL 33634
Learn more about coverage determinations and exceptions on the Centers for Medicaid & Medicare website.
These forms can help you ask for a coverage decision: