Click here to decrease font size
Text Size
Click here to increase font size

Coverage Decisions, Exceptions, Appeals and Complaints

What to do if you have a problem or concern:

Please call us first

Your health and satisfaction are important to us. When you have a problem or concern, please call us. We will work with you to try to find a satisfactory solution to your problem. Please see below for the phone numbers, addresses and/or fax numbers for different types of problems and concerns.

You have rights as a member of our plan and as someone who is getting Medicare. We pledge to honor your rights, to take your problems and concerns seriously, and to treat you with fairness and respect. However, if for some reason your issue isn’t settled to your satisfaction, there are formal steps you can take. 

Please read our Evidence of Coverage for more information. See the section titled What to do if you have a problem or complaint (coverage decisions, appeals, complaints).”

There are two types of formal processes for handling problems and concerns:
 

  • If your problem is about benefits or coverage, you need to use the process for "Coverage Decisions and Making Appeals."
  • If your problem is not about benefits or coverage, you need to skip below to "Member Complaints/Grievances."


Both of these processes have been approved by Medicare. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures and deadlines that must be followed by us and by you.

Coverage Decisions and Appeals

The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for prescription drugs, including problems related to payment. This is the process you use for issues such as whether a drug is covered or not and the way in which the drug is covered.

Asking for coverage decisions

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some instances, WellCare and/or Medicare may decide not to cover certain services or medications. If you disagree with this coverage decision, you can make an appeal.

Making an appeal

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who make the original unfavorable decision. When we have completed the review, we give you our decision.

You, an independent organization that is not connected with our plan (State Health Insurance Assistance Program), doctor or other prescriber, someone else to act on your behalf or your lawyer may ask us for a coverage decision or appeal a decision. If you want someone other than yourself to be your representative, you need to complete the Appointment of Representative form below that gives that person permission to act on your behalf. You must give us a copy of the signed form. 

Appointment of Representative Form (Englishpdf /Spanishpdf)

What is an exception?

If a drug is not covered in the way you would like it to be covered, you can ask the plan to make an “exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception to be approved. We will then consider your request. Here are three examples of exceptions that you or your doctor or other prescriber can ask us to make:
 

  1. Covering a Part D drug for you that is not on our plan's List of Covered Drugs (Formulary).
  2. Removing a restriction on our coverage for a covered drug. There are extra rules or restrictions that apply to certain drugs on our List of Covered Drugs (Formulary).
  3. Changing coverage of a drug to a lower cost-sharing tier. Every drug on the plan's Drug List is in one of the cost-sharing tiers. In general, the lower the cost-sharing tier number, the less you will pay as your share of the cost of the drug.


Important things to know about asking for exceptions

Your doctor must tell us the medical reasons

Your doctor or other prescriber must give us a statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception. Typically our Drug List includes more than one drug for treating a particular condition. These different possibilities are called "alternative" drugs. If an alternative drug would be just as effective as the drug you are requesting and would not cause more side effects or other health problems, we will generally not approve your request for an exception.

You can ask for a coverage decision and/or exception by one of the four following ways:
 

  • Complete our online Request for Medicare Prescription Drug Coverage Determination form.
  • Fax: 1-866-388-1767
  • Call us
  • Write: WellCare Pharmacy Coverage Determinations Department - Pharmacy, P.O. Box 31577, Tampa, FL 33631-3577
  • Overnight Address: WellCare Prescription Insurance, Inc., Attn: Part D Coverage Determinations, 8735 Henderson Rd, Ren. 4, Tampa, FL 33633

 

Learn more about coverage determinations and exceptions on the Centers for Medicare & Medicaid Services website.


These forms can help you ask for a coverage decision:
 


How to make an appeal?

To start your appeal, you, your doctor or your representative must contact our plan. If you are asking for a standard appeal, make your appeal by submitting a written request. If you are asking for a fast appeal, you may make your appeal in writing or you may call us. You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you of our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.

If your health requires it, ask for a "fast appeal." If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it. If we are using the standard deadlines, we must give you our answer within 7 calendar days after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so. If you believe your health requires it, you should ask for "fast" appeal.

There are four ways to file an appeal:
 


You may download the following form to use for your appeal:
 


Independent Review Organizations; also known as Independent Review Entity (IRE)

If our plan says no to your appeal, you then can choose whether to accept this decision or continue making another appeal. If you decide to go on to a Level 2 appeal, the Independent Review Organization reviews the decision our plan made when we said no to your first appeal. This organization decides whether the decision we made should be changed. The Independent Review Organization an independent organization that is hired by Medicare.

Member Complaints/Grievances

The formal name for “making a complaint” is “filing a grievance.”  The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. You can file a grievance or someone you authorize can do so on your behalf.

If you have any of these kinds of problems, you can file a grievance:

 

  • Quality of your medical care
    • Are you unhappy with the quality of the care you received?
  • Respecting your privacy
    • Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confidential?
  • Disrespect, poor customer service, or other negative behaviors
    • Has someone been rude or disrespectful to you?
    • Are you unhappy with how Customer Service has treated you?
    • Do you feel you are being encouraged to leave the plan?
  • Waiting time
    • Have you been kept waiting too long by pharmacists? Or by our Customer Service or other staff at the plan?
  • Cleanliness
    • Are you unhappy with the cleanliness or condition of a pharmacy?
  • Information you get from us
    • Do you believe we have not given you a notice that we are required to give?
    • Do you think written information we have given you is hard to understand?


Contact us promptly - either by phone or in writing. Usually calling our Customer Service is the first step. If you do not wish to call (or you called and were not satisfied) you can put your complaint in writing and send it to us. The complaint must be made within 60 days after you had the problem you want to complain about.

You can also submit a complaint about our plan directly to Medicare.  To submit a complaint to Medicare, go to https://www.medicare.gov/MedicareComplaintForm/home.aspx.  Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. 


If you have any other feedback or concerns, or if you feel the plan is not addressing your issue, please call 1-800-MEDICARE (1-800-633-4227).  TTY users can call 1-877-486-2048.

As a member of our plan, you have the right to file an expedited grievance (fast complaint) for specific circumstances.  An expedited grievance (fast complaint) is resolved within 24 hours. A standard grievance (complaint) is generally resolved within 30 days from the date we receive your request unless your health or condition requires a quicker response. If additional information is required or you can ask for an extension, we may extend that timeframe by up to 14 days.

If you are making a complaint because we denied your request for a “fast coverage decision” or "fast appeal", we will automatically give you a “fast complaint.” If you have a “fast complaint”, we will give you an answer within 24 hours.

You file a grievance in one of the four following ways:
 


Quality Improvement Organizations

You can make your complaint to the Quality Improvement Organization (QIO). If you prefer, you can also make complaint about the quality of care you received directly to this organization (without making a complaint to us). To find the name, address, and phone number of the Quality Improvement Organization in your state, please read your Evidence of Coverage. If you make a complaint to this organization, we will work together with them to resolve your complaint.

If you would like information on how to obtain an aggregate number of grievances, appeals, and exceptions filed with our Plan, current members please contact us.


S5967_NA023901_PDP_WEB_ENG CMS Approved

Last modified: 01/01/2014
 

By clicking on this link, you will be leaving the WellCare website