Skip to main content

Medicare Providers

Size

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.

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 Forms

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.

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 Forms


contact-us

Need help? We're here for you.

Contact Us
Last Updated On: 2/4/2019