WellCare has a coverage determination, appeals, and grievance process for plan members. If you think that WellCare should cover a certain benefit, or a certain medication, or request for an exception to our formulary tiering, you have the right to request a coverage determination.

For situations in which you have a medical service or benefit that you believe is covered or should be covered, you have the right to request a coverage determination. There are two kinds of coverage determination requests - fast and standard. A member can request a fast coverage determination, which will be reviewed within 72 hours. For standard determination requests, notification will occur in 14 days. The request for a fast coverage determination must meet criteria that the standard coverage determination review process time frame would jeopardize the member's health status.

After a coverage determination, if WellCare denies coverage or payment for healthcare services that you think should be covered; you have the right to request an appeal (redetermination). You have the right to request a fast or standard appeal. An expedited appeal request will be reviewed within 72 hrs if the request meets criteria that the standard coverage determination review process time frame would jeopardize the member's health status. For standard appeal requests, notification will occur in 30 days (for a service request) or 60 days (for a request to pay you back) of the receipt of the appeal request.

If the decision of the appeal (redetermination) is to continue the denial of coverage or payment, WellCare will automatically forward your case for reconsideration to Maximus, an independent review entity (IRE) contracted by Medicare to review Managed Care Organizational denials. This IRE has no affiliation with the health plan. Once the review has been filed, the IRE has 30 calendar days (for a standard request for coverage), 60 calendar days (for a request to pay you back) or 72 hours (for expedited requests for coverage) to notify you of their decision. Once they have made a determination on whether to agree or disagree with us, they will notify you of the decision and will provide further appeal instructions.

For situations in which you have a medication that is not on the WellCare formulary or is part of a tier level designated as non-preferred, but you believe it should be placed in a different tier, an exception process has been established by the Plan. Exception requests will be reviewed by the Plan for coverage determination. Your prescribing physician must provide, in response to a coverage exception request related to a non-formulary drug or tiering placement, written documentation of medical necessity for the requested medication.

There are two kinds of coverage determination requests - fast and standard. A member can request a fast coverage determination, which will be reviewed within 24 hours. The request for a fast coverage determination must meet criteria that the standard coverage determination review process time frame would jeopardize the member's health status. For standard coverage determination requests, notification will occur 72 hours after receipt of the request or written documentation of medical necessity from the physician. Non-formulary drugs approved for coverage will be covered at the non-preferred brand level. Biotech and specialty non-formulary products approved for coverage will be covered at the specialty level. A fast coverage determination or exception request can be made verbally by calling 1-866-238-9898 (TTY/TDD users call: 1-866-239-6265) Monday - Sunday, 8:00 a.m. - 2:00 a.m. ET. To make a coverage determination request or an exception request, see instructions and forms below.

Determination Request Form
Drug Evaluation Review Form
Injectible/Infusion Prescription Order Form
Medicare Part D Coverage Determination Request Form

Appeals (Redetermination and Reconsideration)

An appeal is the type of complaint you make when you want us to reconsider and change a decision we have made about what prescription drug benefits are covered for you or what we will pay for a prescription drug. An appeal must be filed within 60 calendar days of the coverage determination. There are two types of appeals - fast and standard. Members can request a fast review of an appeal. The request for a fast appeal must meet criteria that the standard process time frame would jeopardize the member's health status. These fast reviews will be completed within 72 hours. Standard appeal requests for pharmacy benefits will be reviewed within 7 calendar days. Standard appeals requests for medical benefits will be reviewed within 30 calendar days for services not yet received and 60 calendar days for services you have already received. Members can make a fast appeal request by calling 1-866-238-9898. To make a request outside of normal business hours, please call 1-800-351-8777. To make a standard appeal request, see instructions and attached forms below.

IRE Redetermination Form
IRE Reconsideration Form 
Provider Pharmacy Appeal Form
Appointment of Representation Form

For medication appeals, if we continue to make a determination to not approve your request, we will notify you of our decision, verbally and in writing and you are responsible for requesting an IRE reconsideration through Maximus. Our written determination will provide you with further instructions on requesting a second level appeal to the IRE. Once the review has been filed, the IRE has 7 calendar days (for a standard request for coverage or for a request to pay you back) or 72 hours (for expedited requests for coverage) to notify you of their decision.

All coverage determination, appeal, and/or exception requests can be made verbally by calling 1-866-238-9898 (TTY/TDD users call: 1-866-239-6265) Monday - Sunday, 8:00 a.m. - 2:00 a.m. ET. If you have any questions regarding the coverage determination or appeals procedures you can call the number above.

To obtain more information on the aggregate number of WellCare's grievances, appeals, and exceptions, please contact WellCare Customer Service at 1-866-238-9898 (TTY/TDD users call: 1-866-239-6265) Monday - Sunday, 8:00 a.m. - 2:00 a.m. ET.

Grievances

You have the right to file a grievance if you are unsatisfied with WellCare, a provider, or healthcare services you receive.

A grievance is the type of complaint you make if you have any other type of problem with WellCare or one of our network pharmacies. If you have a grievance, we encourage you to call Customer Service. We will try to resolve any complaint over the phone. You may also send your complaint in writing. To submit a grievance in writing, please mail to:

WellCare
Grievance Department
PO Box 31370
Tampa, FL 33631

You can also fax a grievance to: 813-262-2802. We will notify you of a decision within 30 days of receipt of the written grievance. We may extend this time frame by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. An expedited grievance can be made orally by calling 1-866-238-9898 (TTY/TDD users call: 1-866-239-6265) Monday - Sunday, 8:00 a.m. - 2:00 a.m. ET.

Tier Cost Sharing

Tier Cost Sharing is a term that means there is cost sharing for drugs that are classified under tier levels. Each level has co-payment amounts that the member is responsible to pay. The WellCare formulary has five tiers: preferred generic, non-preferred generic, preferred brand, non-preferred brand, and specialty.

If you have any questions about coverage determinations, exception requests, appeals or grievances, please contact Customer Service at 1-866-238-9898 (TTY/TDD users call: 1-866-239-6265) Monday - Sunday, 8:00 a.m. - 2:00 a.m. ET.

Rights and Responsibilities Upon Disenrollment

If a beneficiary disenrolls he/she should remember the following during the disenrollment process:

• Use your WellCare prescription drug coverage and our network pharmacies to fill your prescriptions until your coverage ends.
• If you leave WellCare you can join another Medicare PDP or Medicare Advantage plan as long as this type of plan is available in your area, they are accepting new members, and you meet the eligibility requirements of the plan.
• You may only disenroll or switch plans during certain periods.

WellCare can disenroll a beneficiary in the following circumstances:

• You are no longer eligible for Medicare prescription drug coverage.
• If WellCare is no longer contracting with Medicare or leaves your service area.
• When you move out of WellCare's service area.
• You materially misrepresent a third party reimbursement.
• You fail to pay premium.
• You engage in disruptive behavior, provided fraudulent information when you enrolled, or abuse your enrollment card.