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Forms

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

Appeals & Grievances

Authorizations

This request will be treated as per the standard organization determination time frames.

Behavioral Health Forms

Illinois Behavioral Health Forms


This document includes Harmony and WellCare covered services and authorization guidelines for Community Mental Health Center (CMHC) Services.

This document includes Harmony and WellCare covered services and authorization guidelines for Division of Alcoholism and Substance Abuse (DASA) Services.

Harmony/WellCare IET referral (Engagement Appointment)

Harmony/WellCare IET referral (Initial Appointment)

Claims

Refund Check Information Sheet* (RCIS)

Medical Records

Pharmacy

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

Below are the most commonly prescribed medications that were on the 2018 formulary and their preferred 2019 alternatives.

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

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 Forms

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Last Updated On: 5/8/2017
Beginning January 1, 2019, Harmony Health Plan will become part of MeridianHealth (Meridian). Read More. ×
Welcome Prescription Drug Plan members! We have important information to share with you about your 2019 plan. Read More. ×