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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).
Call: Refer to your Medicare Quick Reference Guide (QRG) for the appropriate phone number. 
Fax: Complete an Appeal of Coverage Determination Request (PDF) and fax it to 1-866-388-1766
Mail: Complete an Appeal of Coverage Determination Request (PDF) 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 (PDF)
  • 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: 5/17/2023