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
Exactus Pharmacy Solutions Enrollment Form
Exactus Pharmacy Solutions Prescription Order Form
Online Form: Request for Medicare Prescription Drug Coverage Determination (Provider & Member)
Request for Medicare Prescription Drug Coverage Determination
- Providers and members should fax form to 1-866-388-1767
WellCare Injectable Infusion
Online Form: Request for Redetermination of Medicare Prescription Drug Denial (Appeal)
Request for Redetermination of Medicare Prescription Drug Denial (Appeal)
Medicare Prescription Drug Coverage and Your Rights
S5967_NA018433_PDP_WEB_ENG CMS Approved MMDDYYYY
Pending CMS Approval
Last modified: 04/09/2012
