Documents and forms
- Annual Notice of Change (for Medicaid and Medicare) (updated 10/1/24)
- Annual Notice of Change (for Medicaid only) (updated 10/1/24)
- Summary of Benefits (for Medicaid and Medicare) (updated 10/1/24)
- Summary of Benefits (for Medicaid only) (updated 10/1/24)
- Evidence of Coverage (for Medicaid and Medicare) (updated 10/1/24)
- Evidence of Coverage (for Medicaid only) (updated 10/1/24)
- LIS Premium Summary Chart (updated 10/1/24)
- List of Covered Drugs (updated 6/30/25)
- Provider and Pharmacy Directory (SNP) (updated 6/30/25)
- Provider and Pharmacy Directory (SCO) (updated 6/30/25)
- Part D Star Rating (updated 10/30/24)
2025 Materiales en Español para Miembros
- Aviso Anual de Cambios (para Medicaid y Medicare) (updated 10/1/24)
- Aviso Anual de Cambios (solo para Medicaid) (updated 10/1/24)
- Resumen de Beneficios (para Medicaid y Medicare) (updated 10/1/24)
- Resumen de Beneficios (solo para Medicaid) (updated 10/1/24)
- Evidencia de Cobertura (para Medicaid y Medicare) (updated 2/5/25)
- Evidencia de Cobertura (solo para Medicaid) (updated 2/5/25)
- Gráfico de Resumen para LIS Premium (updated 10/1/24)
- Lista de Medicamentos (updated 6/30/25)
- Directorio de Proveedores y Farmacias (SNP) (updated 6/30/25)
- Directorio de Proveedores y Farmacias (SCO) (updated 6/30/25)
- Calificación 2024 de Medicare con Estrellas (updated 10/30/24)
- Appointment of Representative Form
- Appointment of Representative Form (large print) (updated 7/14/23)
- Appointment of Representative Form (Spanish) (updated 8/3/23)
- Assign or Revoke a Personal Representative form (updated 7/15/24)
Name someone you know and trust to communicate with our plan on your behalf.- Formulario para designar un representante personal (updated 7/15/24)
- Formulário de Indicação de Representante Pessoal (updated 7/15/24)
- Fòm pou Deziyen yon Reprezantan Pèsonèl (updated 7/15/24)
- Disenrollment form (updated 2/28/24)
- Solicita la desafiliación formulario (updated 2/29/24)
- Model Drug Coverage Determination Form (Medicaid Only) (updated 3/4/25)
Request approval of a prescription drug that is not covered or has restrictions. - Model Drug Coverage Determination Form (Medicaid + Medicare) (updated 3/4/25)
Request approval of a prescription drug that is not covered or has restrictions. - Request for Redetermination of Medicare Prescription Drug Denial Form (updated 3/16/23)
Appeal a decision about drug coverage that you do not agree with. - Over-the-Counter Reimbursement Form (updated 3/16/23)
Request reimbursement for the monthly over-the-counter (OTC) card allowance. - Prescription Reimbursement Form (updated 7/26/23)
Request reimbursement for a prescription that you paid for out-of-pocket.- Formulario de reembolso de recetas (updated 5/13/24)
- Reimbursement Request Form (updated 3/16/23)
Request reimbursement for any medical expenses you may have paid for out-of-pocket.- Formulario de Solicitud de Reembolso (updated 3/16/23)
- Personal Care Attendant (PCA) UM Notification Form (updated 3/16/23)
- PCP Selection Form (updated 6/5/23)
Select or change your Primary Care Provider (PCP) - PHI Permissions for Use Form (updated 6/17/25)
Let us share your Protected Health Information (PHI) with those who need it to provide healthcare services to you.- Permisos para el uso de información protegida de salud (updated 6/17/25)
- Release of Information Form (updated 7/15/24)
Request that we share your information with a third party- Formulario de divulgación de información (updated 7/15/24)
- Formulário de Divulgação de Informações (updated 7/15/24)
- Fòm pou Pibliye Enfòmasyon (updated 7/15/24)
- Release of Reproductive Healthcare Attestation (updated 10/21/24)
- Request for Access to Information Form (updated 7/11/25)
- VSP reimbursement form (updated 1/25/25)
Use this form if you need to be reimbursed for your $325 supplemental vision allowance.
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.