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Administrative

This form can be used to record mileage for member reimbursement.

Authorizations

Behavioral Health

Claims

Refund Check Information Sheet* (RCIS)

Pharmacy

Nebraska Medicaid and Long-Term Care Informed Consent Form for Treatment of Opioid Use Disorder To be completed upon initiation of therapy with Buprenorphine/Naloxone or Buprenorphine

Please complete and submit this form to request coverage through the WellCare of Nebraska Medicaid plan.

Nebraska Tobacco Quitline

Other Forms

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Last Updated On: 5/8/2017