Documents and forms
Here you can find important information regarding the WellSense Added Value (HMO) plan.
Important documents
- Annual Notice of Change (updated 10/1/23)
- Evidence of Coverage (updated 10/1/23)
- List of covered drugs (updated 3/27/24)
- LIS Premium Summary Chart (updated 11/1/23)
- Provider and Pharmacy directory (updated 3/26/24)
- Summary of Benefits (updated 11/10/23)
Member forms and information
- Appointment of Representative form
- Assign or Revoke a Personal Representative form / Formulario para Designar un Representante Personal (updated 7/6/23)
- Auto Pay form (updated 10/4/21)
- Care Management PHI Authorization form (updated 11/12/21)
- Member Rights and Responsibilities
- Prescription Drug Reimbursement Form (updated 4/11/22)
- Release of Information form / Formulario de divulgación de información (updated 7/6/23)
Pharmacy information
- List of covered drugs (updated 3/27/24)
- Prior Authorization drug list (updated 3/27/24)
Here you can find important information regarding the WellSense Signature (HMO) plan.
Important documents
- Annual Notice of Change(updated 10/1/23)
- Evidence of Coverage (updated 10/1/23)
- List of covered drugs (updated 3/27/24)
- LIS Premium Summary chart (updated 10/1/23)
- Provider and Pharmacy directory (updated 3/26/24)
- Summary of Benefits (updated 10/1/23)
Member forms and information
- Appointment of Representative form
- Assign or Revoke a Personal Representative form / Formulario para Designar un Representante Personal (updated 7/6/23)
- Auto Pay form (updated 10/4/21)
- Care Management PHI Authorization form (updated 11/12/21)
- Member Rights and Responsibilities
- Prescription Drug Reimbursement Form (updated 4/11/22)
- Release of Information form / Formulario de divulgación de información (updated 7/6/23)
Pharmacy information
- List of covered drugs (updated 3/27/24)
- Prior Authorization drug list (updated 3/27/24)
Here you can find important information regarding the WellSense Choice (HMO) plan.
Important documents
- Annual Notice of Change (updated 10/1/23)
- Evidence of Coverage (updated 10/1/23)
- List of covered drugs (updated 3/27/24)
- LIS Premium Summary chart (updated 10/1/23)
- Provider and Pharmacy directory (updated 3/26/24)
- Summary of Benefits (updated 10/1/23)
Member forms and information
- Appointment of Representative form
- Assign or Revoke a Personal Representative form / Formulario para Designar un Representante Personal (updated 7/6/23)
- Auto Pay form (updated 10/4/21)
- Care Management PHI Authorization form (updated 11/12/21)
- Member Rights and Responsibilities
- Prescription Drug Reimbursement Form (updated 4/11/22)
- Release of Information form / Formulario de divulgación de información (updated 7/6/23)
Pharmacy information
- List of covered drugs (updated 3/27/24)
- Prior Authorization drug list (updated 3/27/24)
Here you can find important information regarding the WellSense Premium Savings (HMO) plan.
Important documents
- Evidence of Coverage (updated 10/1/23)
- List of covered drugs (updated 3/27/24)
- LIS Premium Summary chart (updated 10/2/22)
- Provider and Pharmacy directory (updated 3/26/24)
- Summary of Benefits (updated 10/1/23)
Member forms and information
- Appointment of Representative form
- Assign or Revoke a Personal Representative form / Formulario para Designar un Representante Personal (updated 7/6/23)
- Auto Pay form (updated 10/4/21)
- Care Management PHI Authorization form (updated 11/12/21)
- Member Rights and Responsibilities
- Prescription Drug Reimbursement Form (updated 4/11/22)
- Release of Information form / Formulario de divulgación de información (updated 7/6/23)
Pharmacy information
- List of covered drugs (updated 3/27/24)
- Prior Authorization drug list (updated 3/27/24)
You are leaving the WellSense website
You are now leaving the WellSense website, and are being connected to a third party web site. Please note that WellSense is not responsible for the information, content or product(s) found on third party web sites.
By accessing the noted link you will be leaving our website and entering a website hosted by another party. Please be advised that you will no longer be subject to, or under the protection of, our privacy and security policies. We encourage you to read and evaluate the privacy and security policies of the site you are entering, which may be different than ours.