Medicare Providers

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  and fax it to 1-866-388-1766.
Mail: Complete an appeal of coverage determination request  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 
• 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