Member Materials and Forms
Thank you for being a WellCare member. On this page, you will be able to quickly find the member materials and forms you may see or need as a member of our plan.
Plan Information and Materials
Enrollment Form 
(Spanish)
Evidence of Coverage
Summary of Benefits
Comprehensive Formulary and Formulary Updates
Plan Ratings
Low Income Subsidy (LIS) Premium Summary Chart
Explanation of Benefits (Sample) (Spanish)
Part D Transition Letter (Sample) (Spanish)
Part D Transition Policy
Payment and Reimbursement Forms
Electronic Funds Transfer
WellCare Direct Member Reimbursement
Authorization Forms
Appointment of Representative (Spanish)
HIPAA Release of Information
HIPAA Release of Information Revocation
Pharmacy Forms
WellCare Member Registration and Prescription Mail-Order
Request for Medicare Prescription Drug Coverage Determination
- Providers and members should fax form to 1-866-388-1767
WellCare Injectable Infusion
Request for Redetermination of Medicare Prescription Drug Denial (Appeal)
S5967_NA016572_PDP_WEB_ENG CMS Approved 11102011
Last modified: 01/17/2012
