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Coverage Determination Appeal

Providers may request a redetermination by submitting an appeal with supporting documentation.

You may file an appeal of a drug coverage decision any of the following ways:

Online: Complete our online Request for Redetermination of Medicare Prescription Drug Denial (Appeal).
Fax: Complete an appeal of coverage determination request This PDF document will open in a new window. and fax it to 1-866-388-1766.
Mail: Complete an appeal of coverage determination request This PDF document will open in a new window. and send it to: 

WellCare, Pharmacy Appeals Department
P.O. Box 31383
Tampa, FL 33631-3383

Basis for Requests

Providers may request coverage or exception for the following:

  • Drugs not listed in the Formulary
  • Duplication of therapy
  • Prescriptions that exceed the FDA daily or monthly quantity limit
  • Most self-injectable and infusion medications This PDF document will open in a new window.
  • Drugs that have an age edit
  • Drugs listed on the PDL but still requiring Prior Authorization (PA)
  • Brand name drugs when a generic exists
  • Drugs that have a step edit (ST) and the first-line therapy is inappropriate
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Last Updated On: 12/3/2019
WellCare will be performing maintenance on Saturday, September 25, 2021 at 6pm EST until Sunday, September 26, 2021 at 6am EST. You might not be able to access systems or fax during this time. We are sorry for any issues this may cause. Thank you for your patience. If you need assistance, contact us. ×