Materials and Forms
Plan Information and Materials
Here you’ll find our enrollment form that you can print out, complete, and mail to WellCare. Mail your completed form to P.O. Box 31411, Tampa, FL 33631-3411.
Evidence of Coverage
This document includes a legal, detailed description of your benefits and costs as a member.
Summary of Benefits
The Summary of Benefits provides some of the features of our plans. For a complete list of benefits, see your Evidence of Coverage.
This document shows you what drugs are covered in a specific plan.
Star Ratings judge how well Medicare health and drug plans perform in different categories. They are distributed by Medicare. Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
Low Income Subsidy (LIS) Premium Summary Chart English Spanish
See what the monthly plan premiums are for those who qualify for Extra Help.
Explanation of Benefits (Sample) (English Spanish)
This is a sample of what an Explanation of Benefits looks like. It details any prescriptions covered in a specific month, what your plan paid and what you paid.
Part D Transition Letter (English Spanish)
This is a sample letter sent to new and existing members who may be subject to plan changes, in order to ensure continuity of care.
Part D Transition Policy
This transition policy applies to Part D medications and ensures a smooth transition for new WellCare members.
Payment and Reimbursement Forms
WellCare Direct Member Reimbursement
Complete this form to request reimbursement for paying full price on a covered prescription drug.
Electronic Funds Transfer
Use this form to authorize a monthly bank withdrawal.
This form confirms you are the court-appointed legal guardian, have power of attorney or are able to make medical decisions on another person’s behalf.
HIPAA Release of Information
This form confirms your permission that WellCare may discuss, or disclose, Protected Health Information (PHI) with a particular person.
HIPAA Release of Information Revocation
This form revokes your permission that WellCare may discuss, or disclose, Protected Health Information (PHI) with a particular person.
Exactus Pharmacy Solutions Enrollment Form
Members can complete this form to register and order prescriptions from Exactus Pharmacy Solutions.
Exactus Pharmacy Solutions Prescription Order Form
At the request of the member, providers can complete, and fax, this form to order prescriptions from Exactus Pharmacy Solutions.
Online Form: Request for Medicare Prescription Drug Coverage Determination (Provider & Member)
Complete, and submit, this form online to request a decision be made regarding a prescription drug and your specific plan coverage.
Request for Medicare Prescription Drug Coverage Determination
Use this form to request a decision be made regarding a prescription drug and your specific plan coverage. This is the same form as above but cannot be submitted electronically. Providers and members should fax form to 1-866-388-1767.
Learn more about coverage determinations and exceptions on the Centers for Medicare & Medicaid Services website.
WellCare Injectable Infusion
Complete this form to request a review of coverage for injectable/infusion drugs.
Online Form: Request for Redetermination of Medicare Prescription Drug Denial (Appeal)
You can submit this form online to ask for an appeal after being denied a request for coverage, or payment, for a prescription drug.
Request for Redetermination of Medicare Prescription Drug Denial (Appeal)
Complete this form to ask for an appeal after being denied a request for coverage, or payment, for a prescription drug. This is the same form as above but cannot be submitted electronically.
Medicare Prescription Drug Coverage and Your Rights
This document outlines your rights with regards to your Medicare drug plan.
S5967_NA023901_PDP_WEB_ENG CMS Approved