Coverage Determinations and Redeterminations for Drugs

A coverage determination, also called an exception, is a decision about whether a drug prescribed for you will be covered by us and how much you may need to pay. If a drug is not covered, or if there are restrictions or limits on a drug, you may request a coverage determination.

What You Can Request

You can ask us to cover:

• A drug that is not on our covered List of Drugs (Formulary).
  • To view the formulary search tool for your specific Wellcare By Fidelis Care plan, visit our Prescription Drug Information page and select the Prescription Drug Formularies accordion.
• 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 medically necessary for your condition.

We must make our decision and respond within 72 hours after we receive your doctor’s statement. If we deny your request, you can appeal our decision. Information about how to file an appeal will be included in the denial letter.

Generally, we will approve your request only if the alternative drug on our List of Drugs, a lower-tier drug, or the applicable coverage restrictions would not treat your condition as effectively. Contact information is provided below. You can also call Member Services at 1-888-343-3547 (TTY: 711).

Members can request a coverage determination on or after January 1, 2027. Any request submitted before this date will be evaluated only for the current benefit year.

Drug Coverage Determination Forms

• Online Form:
  • Drug Coverage Determination Online Request
• Paper Form:
  • Drug Coverage Determination Request Form

How to Request a Coverage Determination

You can request a coverage determination or exception in one of the following ways:

By Mail

By Fax

Fax: 1-866-226-1093

By Phone

Call Member Services at 1-888-343-3547 (TTY: 711).

For Doctors and Other Prescribers Only

Electronic Prior Authorization

Submit an electronic prior authorization through the CoverMyMeds Prior Authorization Portal .

Medicare Part D Hospice Forms

Access the Medicare Part D hospice form and instructions through Hospice Information and Forms .

Send the completed Medicare Part D Hospice Prior Authorization form using one of the following methods:

By Mail

By Fax

Fax: 1-866-226-1093

For questions or assistance, doctors and prescribers can call 1-800-867-6564 (TTY: 711).

Standard and Fast Coverage Determination Decisions

If you or your doctor believes that waiting 72 hours for a standard decision could seriously harm your health, you can ask for a fast, or expedited, decision. This option is available only for Part D drugs that you have not already received.

We must make an expedited decision within 24 hours after we receive your doctor’s supporting statement. If we do not receive your doctor’s supporting statement for an expedited request, we will decide whether your case requires a fast decision.

If we approve your drug exception, the approval will remain in effect 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 the drug, and the drug must remain safe for treating your condition.

After we make a coverage decision, we will send you a letter explaining our decision. The letter will also include information about how to appeal a denied request.

Prescription Reimbursement

To ask us to reimburse you for prescriptions you paid for out of pocket, complete the following steps:

1. Complete the Prescription Drug Claim Form using the link below.
2. If another person will complete the form on your behalf, include the Appointment of Representative Form, CMS-1696, with your Prescription Drug Claim Form. This form is available through the link below and on the Centers for Medicare & Medicaid Services (CMS) website.
3. Add the prescription label information to the form and include proof of payment for each claim you submit. If you do not have a receipt or the information needed to complete the form, ask your pharmacy for assistance.
4. Mail the completed form or forms and receipt or receipts to the address listed on the form. You must submit your claim within three years of the date you received the drug.
5. Keep a copy of the forms and receipts for your records.

Prescription Drug Claim Form

• Prescription Drug Claim Form – English (PDF)

Appointment of Representative Forms

• Appointment of Representative Form CMS-1696 – English (PDF)
• Nombramiento de Representante, Formulario CMS-1696 – Español (PDF)

After we receive your request, we will mail our decision, along with a reimbursement check if applicable, within 14 days.

For specific information about your drug coverage, refer to your Evidence of Coverage or call Member Services at 1-888-343-3547 (TTY: 711).

Redeterminations (Appeals)

If we deny your request for coverage of, or payment for, a drug, you, your doctor, or your representative may request a redetermination, also called an appeal.

You have 65 days from the date of our coverage denial letter to request a redetermination. You may complete the Redetermination Form, but you are not required to use it. You can send the form or another written request by mail or fax.

By Mail

By Fax

Fax: 1-866-388-1766

Expedited Redeterminations

You can request an expedited redetermination by calling Member Services at 1-888-343-3547 (TTY: 711).

If you or your doctor states that waiting seven days for a standard decision could seriously harm your health or your ability to regain maximum function, you can ask for a fast decision.

If your doctor supports the request, we will automatically provide a decision within 72 hours. If we do not receive your doctor’s supporting statement, we will decide whether your case requires a fast decision.

You cannot request an expedited appeal if you are asking us to reimburse you for a drug you have already received.

Drug Coverage Redetermination Forms

• Online Form:
  • Drug Coverage Redetermination Online Request
• Paper Form:
  • Request for Redetermination Form

For more information about Medicare member rights, visit our Rights, Appeals, and Disputes page.

For more information about coverage determinations, exceptions, redeterminations, and appeals, refer to your Evidence of Coverage on our Medicare Resources page.