Coverage Determinations and Redeterminations for Drugs

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 Member Services.

Standard and Fast 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 applies only to requests 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 approve your drug’s exception, the approval continues until the end of the plan year. To keep the exception in place for the plan year, 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 decision, we send you a notice explaining our decision. The notice includes information on how to appeal a denied request.

Prescription Reimbursement

If you need to ask us to pay you back for prescriptions paid out-of-pocket:

1. Complete the Prescription Drug Claim Form using the link below.
2. If you want another person to complete this form on your behalf, please include the Appointment of Representative (AOR) Form CMS-1696 with your Prescription Drug Claim Form. This form is located at the link below and can also be found on the Centers for Medicare & Medicaid Services (CMS) website.
3. Add the prescription label information to the form and include a proof of payment receipt for each claim you submit. If you do not have the receipt or the information needed to fill out the form, you can ask your pharmacy to help. 
4. Mail the completed form(s) and receipt(s) to the address on the form.  You must submit your claim to us within three years of the date you received your drug.
5. It is also a good idea to keep a copy of the forms and receipts for your records.

Prescription Drug Claim Form - English (PDF)

Prescription Drug Claim Form - Spanish (PDF)

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), Member Handbook or contact Member Services.

Redeterminations (Appeals)

If we deny your request for coverage of (or payment for) a drug, you, your doctor, or your representative may ask us for a redetermination (appeal). You have 60 days from the date of our denial notice to request a redetermination. You can complete the Redetermination form, but you are not required to use it. You can send the form, or other written request, by mail or fax to:

Wellcare By Health Net
Attn: Medicare Pharmacy Appeals
P.O. Box 31383
Tampa, FL 33631-3383
Fax: 1-866-388-1766

An expedited redetermination (appeal) request can be made by phone at Member Services.

If you or your doctor states that waiting 7 days for a standard decision could seriously harm your health or ability to regain maximum function, you can ask for a fast (expedited) decision. If your doctor states this, we will automatically give you a decision within 72 hours. If we do not receive your doctor’s supporting statement for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

For more information about coverage determinations (exceptions) and redeterminations (appeals), please refer to your Evidence of Coverage (EOC). 

Coverage Determinations and Redeterminations for Drugs

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 covered 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 Member Services.

Standard and Fast 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 applies only to requests 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 approve your drug’s exception, the approval continues until the end of the plan year. To keep the exception in place for the plan year, 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 decision, we send you a notice explaining our decision. The notice 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 Prescription Drug Claim Form using the link below.
2. If you want another person to complete this form on your behalf, please include the Appointment of Representative (AOR) Form CMS-1696 with your Prescription Drug Claim Form. This form is located at the link below and can also be found on the Centers for Medicare & Medicaid Services (CMS) website.
3. Add the prescription label information to the form and include a proof of payment receipt for each claim you submit. If you do not have the receipt or the information needed to fill out the form, you can ask your pharmacy to help. 
4. Mail the completed form(s) and receipt(s) to the address on the form.  You must submit your claim to us within three years of the date you received your drug.
5.   It is also a good idea to keep a copy of the forms and receipts for your records.

Prescription Claim Form - English (PDF)

Prescription Claim Form -  Spanish (PDF)

Appointment of Representative (AOR Form) _CMS-1696 - English (PDF)

Appointment of Representative (AOR Form) CMS-1696 - Spanish (PDF)

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), Member Handbook or contact Member Services.

Redeterminations (Appeals)

If we deny your request for coverage of (or payment for) a drug, you, your doctor, or your representative may ask us for a redetermination (appeal). You have 65 days from the date of our coverage denial letter to request a redetermination. You can complete the Redetermination form, but you do not have to use it. You can send the form, or other written request, by mail or fax to:

Wellcare By Health Net
Attn: Medicare Pharmacy Appeals
P.O. Box 31383
Tampa, FL 33631-3383
Fax: 1-866-388-1766

An expedited redetermination (appeal) request can be made by phone at Member Services or refer to the number on the back of your Member ID card.

If you or your doctor states that waiting 7 days for a standard decision could seriously harm your health or ability to regain maximum function, you can ask for a fast (expedited) decision. If your doctor states this, we will automatically give you a decision within 72 hours. If we do not receive your doctor’s supporting statement for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

More Information

For more information about coverage determinations (exceptions) and redeterminations (appeals), please refer to your Evidence of Coverage (EOC).