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Mga Eksepsiyon (Part D)

Coverage Determinations (Exceptions Part D)

 A coverage determination (exception) is a decision about whether a drug prescribed for you will be covered by us and the amount you’ll need to pay, if any. If a drug is not covered or there are restrictions or limits on a drug, you may request a coverage determination.

You can ask us to cover:

  • a drug that is not on our List of Drugs (Formulary)
  • a drug that requires prior approval
  • a drug at a lower cost sharing tier, as long as the drug is not on the specialty tier (Tier 5)
  • a higher quantity or dose of a drug

You, your representative, or your doctor may submit a coverage determination request by fax, mail, or phone. You must include your doctor’s statement explaining why the drug is necessary for your condition. Within 72 hours after we receive your doctor’s statement, we must make our decision and respond. If we deny your request, you can appeal our decision. Information on how to file an appeal will be included in the denial letter.

Generally, we will approve your request only if the alternative drug is on our list of drugs, or if a lower cost-sharing drug or added restrictions don't treat your condition as well. The contact information is listed below. You also can Contact Us.

You can ask for a coverage determination (exception) one of the following ways:

Drug Coverage Determination Forms:
Drug Coverage Determination Form Magbubukas ang PDF na dokumentong ito sa bagong window.

Online: Complete our online Request for Medicare Drug Coverage Determination form. This can be found on your plan’s Pharmacy page.

Mail: Wellcare Health Plans Pharmacy – Coverage Determinations
           P.O. Box 31397
           Tampa, FL 33631-3397

Overnight address:
Wellcare Health Plans Pharmacy – Coverage Determinations
8735 Henderson Road, Ren.4
Tampa, FL 33634

Fax:   1-866-388-1767

PhoneContact Us or refer to the number on the back of your Wellcare Member ID card.

For Doctors and other Prescribers ONLY:

Electronic Prior Authorization (ePA) at: Cover My Meds prior authorization portal
Phone: 1-855-538-0454

Standard and Fast Coverage Determination Decisions

If you or your doctor believe that waiting 72 hours for a standard decision could seriously harm your health, you can ask for a fast (expedited) decision. This is only for Part D drugs that you have not already received. We must make expedited decisions within 24 hours after we get your doctor’s supporting statement. If we do not receive your doctor’s supporting statement for an expedited request, we will decide if your case requires a fast decision.

If we approve your drug’s exception, the approval will be until the end of the plan year. To keep the exception in place, you must remain enrolled in our plan, your doctor must continue to prescribe your drug, and your drug must be safe for treating your condition.

After we make a coverage decision, we send you a letter explaining our decision. The letter includes information on how to appeal a denied request.

Prescription Reimbursement

If you need to ask for reimbursement for prescriptions paid out-of-pocket:

  1. Complete the Prescription Claim FormMagbubukas ang PDF na dokumentong ito sa bagong window.
  2. Attach the original prescription receipt to the form. If you do not have the original receipt, you can ask your pharmacy for a printout. Do not use cash register receipts.
  3. Mail the completed form and receipt to the address on the form.

After we receive your request, we will mail our decision (determination) with a reimbursement check (if applicable) within 14 days. For specific information about drug coverage, refer to your Evidence of Coverage (EOC) or Contact Us.

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Y0020_WCM_87476E Huling Na-update Noong: 10/1/2021