Wellcare Giveback (HMO)

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:

• Online: Complete our online Request for Medicare Drug Coverage Determination form.
• Drug Coverage Determination Form: Request for Prescription Drug Coverage (PDF)
  • 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
• Phone: Contact 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

Medicare Part D Hospice Forms at: Hospice Information and Forms (PDF)
Please send the completed Medicare Part D Hospice Prior Authorization form one of the following ways:

• Fax: 1-866-226-1093
• Mail: Wellcare Medicare Pharmacy Prior Authorization Department
             P.O. Box 31397
             Tampa, FL 33631-3397 

For questions or assistance please call our Doctor/Prescriber Phone: 1-800-867-6564 (TTY: 711)

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 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.

• Prescription Drug Claim Form - English (PDF)
• Prescription Drug 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) or Contact Us.