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Web request for redetermination of medicare prescription drug denial (appeal) (pdf) this form may be sent to us by mail. Web provider request for reconsideration and claim dispute form. Use this form as part of the wellcare of north carolina. Web claim” process in the wellcare by allwell provider manual, found on superiorhealthplan.com/providermanuals. Web forms | wellcare. Web you can now quickly request an appeal for your drug coverage through the request for redetermination form.