Pharmacy forms
- Pharmacy Appeal Form
- Brand Penalty Waiver Form
- Preventive Services Zero Copay Exception Form
- Personal Representative Appointment and Authorization to Release Protected Health Information Form
- CVS Global Authorization Form
- Prescription Reimbursement Claim Form
- Specialty Medication Early Refill Request
The definitions section may be helpful in understanding the pharmacy terms used on this page.
Frequently asked questions
Find answers to common questions below, including who may file an appeal, where to send it and what to do if you disagree with a coverage decision.
Please use the pharmacy appeal form below to request an internal appeal or an external review of a denial related to a pharmacy prior authorization, brand penalty waiver or formulary exception.
The appeal request should include:
- The Pharmacy Appeal Form
- Date
- Name and address
- Your Wellmark ID number (found on your Wellmark ID Card)
- Supporting documents (doctor’s notes, patient chart, initial denial letter and any information supporting your claim).
You, your prescribing provider or someone you name to act for you (your authorized representative) may file an appeal. This could be your doctor, a relative, a friend, an advocate, an attorney or anyone else you appoint. To appoint an authorized representative, please complete the Personal Representative Appointment and Authorization to Release Protected Health Information Form
IMPORTANT: Before submitting a pharmacy appeal, review the appeal rights in your denial notice or adverse benefit determination letter. It explains your rights, how and where to submit your appeal and important timelines.
Fill out the Pharmacy Appeal Form and send to the fax number or address listed below.
Retail Pharmacy Medications
Mail or fax your request to:
CVS Caremark Prescription Claim Appeals MC 109
P.O. Box 52084
Phoenix, AZ 85072
Fax: 1-866-443-1172
Specialty Pharmacy Medications
Mail or fax your request to:
CVS Caremark Specialty Appeals Department
800 Biermann Court
Mount Prospect, IL 60056
Fax: 1-855-230-5548
Wellmark works with CVS Caremark® to help process pharmacy appeals for our members. While CVS Caremark may handle parts of the review, Wellmark remains responsible for your coverage and final decision.
We are here to help. If you have questions, contact Wellmark customer service at the number on the back of your Wellmark ID card.
The review and appeal process
If you wish to file an appeal, follow the instructions below, starting with the initial review.
Wellmark reviews your request to see if your medication can be covered.
- Prescription not covered: you go the pharmacy and your medication is not covered.
- Possible reason for denial: the medication may not be on your plan's formulary, may not be medically necessary or may need prior approval.
- Submit your request: your or your doctor can submit a request for review and include medical documentation.
- Wellmark review: Wellmark reviews your initial request and the information provided.
- You receive a decision: you will be notified, by letter, whether the medication will be covered or your request has been denied (depending on your coverage criteria).
- Decision or outcome:
- Approved: Your medication is covered
- Denied: Your medication is not covered
If denied, what happens next?
File an Internal Appeal: you, your personal representative or your doctor can file an internal appeal to request another review of the decision.
- Denial letter received: carefully review your denial letter to better understand your options.
- Talk with your doctor: check with your doctor to see if a different medication might be right for you.
- Submit your appeal: if your doctor believes this medication is the best option for your condition, you or your doctor can complete the appeal form and submit with supporting medical documentation.
- Clinical review of your appeal: your appeal will be reviewed by another medical professional with similar knowledge of your doctor.
- Decision made: a decision will be made to approve or deny your appeal.
- You or your doctor will be notified: you and your doctor will be notified with an explanation of the decision.
- What happens if my appeal is denied? You may have the right to an external review.
If you have completed an internal appeal and it was denied, and you disagree with the decision, you may have the right to request an external review by an Independent Review Organization (IRO). External review may not be available for all members; refer to your denial letter for your specific appeal rights.
An expedited external review is available if a delay in treatment could seriously jeopardize your health, life or ability to regain maximum function.
IMPORTANT: Your denial letter includes instructions on how and where to submit your external review request. Depending on your plan, requests may be sent to your state’s insurance division or to CVS Caremark®, which works on behalf of Wellmark to process pharmacy appeals. Please review the instructions in your denial letter to ensure your external review request goes to the correct entity.
Insurance Division | Iowa and South Dakota
File an Iowa Pharmacy External Review Request (Iowa Insurance Division)
File a South Dakota Pharmacy External Review Request (South Dakota Insurance Division)
CVS Caremark
Retail Pharmacy Medications
Mail or fax your request to:
CVS Caremark Prescription Claim Appeals MC 109
P.O. Box 52084
Phoenix, AZ 85072
Fax: 1-866-443-1172
Specialty Pharmacy Medications
Mail or fax your request to:
CVS Caremark Specialty Appeals Department
800 Biermann Court
Mount Prospect, IL 60056
Fax: 1-855-230-5548
If you have questions, call Wellmark customer service at the number on the back of your Wellmark ID card.
Steps for an external review:
- Review your denial letter: carefully review your denial letter to better understand your options and whether you are eligible for an external review.
- Determine who will review your case: visit your state's insurance division website to determine who will review your appeal.
- Take the right path to get started: state insurance division: visit their website to follow the correct process for submission
Wellmark/CVS: Complete the appeal form and submit to the address included in your denial letter. - Send supporting information: send medical documents for the case to be reconsidered, including medical necessity of the medication.
- Third party independent review: your case will be reviewed by a neutral and independent third party who specializes in the condition being treated.
- Decision made: a decision will be made to approve or deny your external review.
At this time, you have exhausted all internal and external appeal rights available to you under your plan and federal law. However, you may have other remedies available to you under state or federal law, such as filing a lawsuit. - You will be notified of decision: you and your doctor will be notified of the decision made regarding the external review.
- If the request is denied, you have two options: pay for the medication out of pocket or choose a different medication.
Definitions
- A Prior Authorization is when your doctor needs approval from Wellmark before you receive certain treatments, tests or medications to determine if they are covered under your plan and meet medical necessity and coverage requirements for your condition.
- A Formulary Exception is a request for your plan to cover a medication that is not typically covered because other medications on the formulary are considered preferred treatment options. Your doctor can request an exception if the medication is medically necessary for you.
- A Brand Penalty is an extra cost you may pay if you choose a brand-name medication when a lower-cost generic option is available and covered under your plan.
- An Internal Appeal is when you ask Wellmark to review a coverage denial again and consider any additional information you or your doctor provide.
- An External Review is when an independent, neutral third-party reviewer outside of Wellmark reviews your case to determine if your service or treatment should be covered after an internal appeal is denied.
- Preventive Services Zero Copay Exception offers the option for a member or a provider to request a zero-dollar coverage exception review when the requested drug is medically necessary for the patient as a preventive service.