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Forms

Access key forms for authorizations, claims, pharmacy and more.

Appeals & Grievances

Claims

Form must be completed in full, and used only when submitting 1 refund check per claim.

Medical Records

Pharmacy

This list includes the most commonly prescribed medications that were on the 2016 formulary and their preferred 2017 alternatives.

Please complete ALL FIELDS and fax this form to WellCare’s Pharmacy Department at 1-866-388-1767.

Please complete ALL FIELDS and fax this form to WellCare’s Pharmacy Department at 1-866-388-1767.

Please complete ALL FIELDS and fax this form to WellCare’s Pharmacy Department at 1-866-388-1767.

Please complete ALL FIELDS and fax this form to WellCare’s Pharmacy Department at 1-866-388-1767.

Please complete ALL FIELDS and fax this form to WellCare’s Pharmacy Department at 1-866-388-1767.

Fill out and submit this form to request prior authorization (PA) for your Medicare prescriptions.

Fill out and submit this form to request an appeal for Medicare medications.

Other Provider Other Forms

Care of Older Adult Assessment Form

Appendix 7 - Waiver of Liability Statement (Rev. 105, Issued: 04-20-12, Effective: 04-20-12, Implementation: 04-20-12)


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Last Updated On: 1/12/2018
The Governor has declared a State of Emergency in Los Angeles County, due to the ongoing wild fires. If you are an affected member and need access to medical or pharmacy services, please call Member Services at 1-866-999-3945 for assistance. ×