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Materials and Forms

Thank you for being a WellCare member. On this page, you will be able to quickly find our plan materials & forms.
 


Plan Information and Materials

Enrollment Form
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.
 

Comprehensive Formulary
This document shows you what drugs are covered in a specific plan.

Star Ratings
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 Englishpdf Spanishpdf 
See what the monthly plan premiums are for those who qualify for Extra Help.

Explanation of Benefits (Sample) (Englishpdf Spanishpdf)
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 (Englishpdf Spanishpdf
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 Reimbursementpdf
Complete this form to request reimbursement for paying full price on a covered prescription drug.

 

Electronic Funds Transferpdf
Use this form to authorize a monthly bank withdrawal.


 

Authorization Forms

Appointment of Representative (Englishpdf Spanishpdf)
This form confirms your request for a particular person to act as your representative in connection with a claim.

 

Notice of Attestationpdf

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 Informationpdf 
This form confirms your permission that WellCare may discuss, or disclose, Protected Health Information (PHI) with a particular person.

HIPAA Release of Information Revocation
pdf
This form revokes your permission that WellCare may discuss, or disclose, Protected Health Information (PHI) with a particular person.

 

Pharmacy Forms

Exactus Pharmacy Solutions Enrollment Form pdf
Members can complete this form to register and order prescriptions from Exactus Pharmacy Solutions.
 
Exactus Pharmacy Solutions Prescription Order Form pdf
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 pdf
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 Infusionpdf
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) pdf
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 pdf
This document outlines your rights with regards to your Medicare drug plan.


S5967_NA023901_PDP_WEB_ENG CMS Approved

Last modified: 01/01/2014
 

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