[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-283814-105":53,"doc-detail-283814-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","request-for-medicare-drug-coverage-determination-request-a-coverage-decision","REQUEST FOR MEDICARE DRUG COVERAGE DETERMINATION - Request a Coverage Decision","","Request form for Medicare drug coverage determinations used to ask a plan for an approval decision. It collects plan enrollee and requestor information, including member ID, contact details, and the drug name with dosage and quantity. It supports requests such as reimbursement, prior authorization, formulary exceptions, quantity-limit exceptions, prior-authorization rule exceptions, and tiering exceptions, including expedited decisions when delays could seriously harm health. 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If someone other than the enrollee or prescriber submits it, authority must be documented.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What types of coverage determination requests does this form support?",{"text":114,"@type":110},"It supports requests for higher copayment reimbursement, reimbursement for covered drugs already paid out of pocket, prior authorization, formulary exceptions, exceptions to try-another-drug requirements, quantity-limit exceptions, prior-authorization rule exceptions, and tiering exceptions.",{"name":116,"@type":107,"acceptedAnswer":117},"When can an expedited decision (within 24 hours) be requested?",{"text":118,"@type":110},"An expedited decision can be requested when waiting 72 hours for a standard decision could seriously harm the enrollee’s life, health, or ability to regain maximum function. The prescriber’s support is required, and expedited requests cannot be used to ask the plan to pay back for a drug already received.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},283814,1790463151,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":136,"language":137,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":61,"update_tm":141,"read_time":76},7971461740909,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","REQUEST FOR MEDICARE DRUG COVERAGE DETERMINATION  \nUse this form to ask our plan for a coverage determination. You can also ask for a coverage determination by calling Member Services at the number on your ID card (TTY 711) or through our [website at www.wellcare.com/Medicare. From October](website at www.wellcare.com/Medicare. From October) 1 to March 31, you can call us 7 days a [week from 8 a.m. to 8 p.m. From Apri](week from 8 a.m. to 8 p.m. From Apri)l 1 to September 30, you can call us Monday through Friday [from 8 a.m. to 8 p.m. A messaging](from 8 a.m. to 8 p.m. A messaging) system is used after hours, weekends, and on federal holidays. You, your doctor or prescriber, or your authorized representative can make this request.  \nPlan Enrollee  \n\n| Name | Date of birth |\n| --- | --- |\n| Street address | City |\n| State | ZIP |\n| Phone | Member ID \\# |\n\nIf the person making this request isn’t the plan enrollee or prescriber:  \n\n| Requestor’s name |\n| --- |\n| Relationship to plan enrollee |\n| Street address (include City, State and ZIP ) |\n| Phone |\n| 􀂅 Submit documentation with this form showing your authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or equivalent) . For more information on appointing a representative, contact our plan or call 1-800-MEDICARE.(1-800-633-4227) . TTY users can call 1-877-486-2048. |\n\nName of drug this request is about (include dosage and quantity information if available)  \nY0020_WCM_ 172945E_C Internal Approved 01222025 NA5WCMFRM75847E_0000  \nType of Request  \n☐ My drug plan charged me a higher copayment for a drug than it should have ☐ I want to be reimbursed for a covered drug I already paid for out of pocket  \n☐ I’m asking for prior authorization for a prescribed drug (this request may require supporting information)  \nFor the types of requests listed below, your prescriber MUST provide a statement supporting the request. Your prescriber can complete pages 3 and 4 of this form, “Supporting Information for an Exception Request or Prior Authorization.”  \n☐ I need a drug that’s not on the plan’s list of covered drugs (formulary exception)☐ I’ve been using a drug that was on the plan’s list of covered drugs before , but has been or will be removed during the plan year (formulary exception)  \n☐ I’m asking for an exception to the requirement that I try another drug before I get a prescribed drug (formulary exception)  \n☐ I’m asking for an exception to the plan’s limit on the number of pills (quantity limit) I can get so that I can get the number of pills prescribed to me (formulary exception)  \n☐ I’m asking for an exception to the plan’s prior authorization rules that must be met before I get a prescribed drug (formulary exception) .  \n☐ My drug plan charges a higher copayment for a prescribed drug than it charges for another drug that treats my condition, and I want to pay the lower copayment (tiering exception)  \n☐ I’ve been using a drug that was on a lower copayment tier before , but has or will be moved to a higher copayment tier (tiering exception)  \nAdditional information we should consider (submit any supporting documents with this form):  \nDo you need an expedited decision?  \nIf you or your prescriber believe that waiting 72 hours for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 72 hours could seriously harm your health, we’ll automatically give you a decision within 24 hours. If you don’t get your prescriber's support for an expedited request , we’ll decide if your case requires a fast decision. (You can’t ask for an expedited decision if you’re asking us to pay you back for a drug you already received. )☐ YES, I need a decision within 24 hours. If you have a supporting statement from your prescriber, attach it to this request.  \n\n| Signature: | Date: |\n| --- | --- |\n\nHow to submit this form  \nSubmit this","cbCaic2mzIdrkKVO","https://ap.wps.com/l/cbCaic2mzIdrkKVO","pdf",769654,9,"English","# Plan Enrollee Information\n## Requestor Information (If Not the Enrollee or Prescriber)\n# Drug and Type of Request\n## Types of Requests\n# Additional Information and Expedited Decision\n## Expedited Review Eligibility\n# How to Submit the Form\n# Supporting Information for an Exception Request or Prior Authorization\n## Prescriber Information\n## Diagnosis and Medical Information\n## Drug History\n## Current Drug Regimen","[{\"question\":\"Who can submit a request for a Medicare drug coverage determination?\",\"answer\":\"The request can be made by the plan enrollee, the doctor or prescriber, or an authorized representative. If someone other than the enrollee or prescriber submits it, authority must be documented.\"},{\"question\":\"What types of coverage determination requests does this form support?\",\"answer\":\"It supports requests for higher copayment reimbursement, reimbursement for covered drugs already paid out of pocket, prior authorization, formulary exceptions, exceptions to try-another-drug requirements, quantity-limit exceptions, prior-authorization rule exceptions, and tiering exceptions.\"},{\"question\":\"When can an expedited decision (within 24 hours) be requested?\",\"answer\":\"An expedited decision can be requested when waiting 72 hours for a standard decision could seriously harm the enrollee’s life, health, or ability to regain maximum function. The prescriber’s support is required, and expedited requests cannot be used to ask the plan to pay back for a drug already received.\"}]","REQUEST FOR MEDICARE DRUG COVERAGE DETERMINATION - Request a Coverage Decision | PDF",1789620207]