Skip to main content

Medicare Providers

Size

Forms

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


Appeals & Grievances

Provider Waiver of Liability (WOL) Statement

Authorizations

Medical Admission Fax Cover Sheet

State-Specific Authorization Forms

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

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

Behavioral Health

Claims

Refund Check Information Sheet* (RCIS)

Medical Records

Pharmacy

This policy provides a list of drugs that require step therapy. Step therapy is when we require the trial of a preferred therapeutic alternative prior to coverage of a non-preferred drug for a specific indication.

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.

Drug Prior Authorization Requests Supplied by the Physician/Facility

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.

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.

Other Provider Forms


contact-us

Need help? We're here for you.

Contact Us
Last Updated On: 5/12/2021