Documents and Forms
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Here you can find important information regarding the 2022 WellSense Medicare Advantage (HMO) plan.
Important documents
- Evidence of Coverage
- List of Covered Drugs
- LIS Premium Summary chart
- Provider and Pharmacy directory
- Summary of Benefits
Member forms and information
- Auto Pay Form
- Care Management PHI Authorization Form
- Fitness Reimbursement Form
- Member Rights and Responsibilities
- Prescription Reimbursement Form
Pharmacy Information
Here you can find important information regarding the 2022 WellSense Medicare Advantage (HMO) plan.
Important documents
- Evidence of Coverage
- List of Covered Drugs
- LIS Premium Summary chart
- Provider and Pharmacy directory
- Summary of Benefits
Member forms and information
- Auto Pay Form
- Care Management PHI Authorization Form
- Fitness Reimbursement Form
- Member Rights and Responsibilities
- Prescription Reimbursement Form
Pharmacy Information
Here you can find important information regarding the 2023 WellSense Added Value (HMO) plan.
Important documents
- Evidence of Coverage
- List of Covered Drugs
- LIS Premium Summary chart
- Provider and Pharmacy directory
- Summary of Benefits
Member forms and information
- Auto Pay Form
- Care Management PHI Authorization Form
- Fitness Reimbursement Form
- Member Rights and Responsibilities
- Prescription Reimbursement Form
Pharmacy Information
- List of Covered Drugs
- Prior Authorization Drug List
Here you can find important information regarding the 2023 WellSense Signature (HMO) plan.
Important documents
- Evidence of Coverage
- List of Covered Drugs
- LIS Premium Summary chart
- Provider and Pharmacy directory
- Summary of Benefits
Member forms and information
- Auto Pay Form
- Care Management PHI Authorization Form
- Fitness Reimbursement Form
- Member Rights and Responsibilities
- Prescription Reimbursement Form
Pharmacy Information
- List of Covered Drugs
- Prior Authorization Drug List
Here you can find important information regarding the 2023 WellSense Choice (HMO) plan.
Important documents
- Evidence of Coverage
- List of Covered Drugs
- LIS Premium Summary chart
- Provider and Pharmacy directory
- Summary of Benefits
Member forms and information
- Auto Pay Form
- Care Management PHI Authorization Form
- Fitness Reimbursement Form
- Member Rights and Responsibilities
- Prescription Reimbursement Form
Pharmacy Information
- List of Covered Drugs
- Prior Authorization Drug List
Here you can find important information regarding the 2022 WellSense Medicare Advantage (HMO) plan.
Important documents
- Evidence of Coverage (updated 4/26/22)
- List of Covered Drugs (updated 10/31/22)
- LIS Premium Summary chart (updated 4/26/22)
- Provider and Pharmacy directory (updated 10/21/22)
- Summary of Benefits (updated 4/26/22)
Member forms and information
- Auto Pay Form (updated 10/4/21)
- Care Management PHI Authorization Form (updated 11/12/21)
- Designated Personal Representative Form (updated 11/16/22)
- Fitness Reimbursement Form (updated 12/21/21)
- Member Rights and Responsibilities
- Prescription Reimbursement Form (updated 4/11/22)
Pharmacy Information
- List of Covered Drugs (updated 10/31/22)
- Prior Authorization Drug List (updated 10/31/22)
Here you can find important information regarding the 2023 WellSense Added Value (HMO) plan.
Important documents
- Evidence of Coverage (updated 9/20/22)
- List of Covered Drugs (updated 9/20/22)
- LIS Premium Summary chart (updated 10/2/22)
- Provider and Pharmacy directory (updated 10/21/22)
- Summary of Benefits (updated 11/15/22)
Member forms and information
- Auto Pay Form (updated 10/4/21)
- Care Management PHI Authorization Form (updated 11/12/21)
- Designated Personal Representative Form (updated 11/16/22)
- Member Rights and Responsibilities
- Prescription Reimbursement Form (updated 4/11/22)
Pharmacy Information
- List of Covered Drugs (updated 9/20/22)
- Prior Authorization Drug List (updated 10/12/22, under CMS review)
Here you can find important information regarding the 2023 WellSense Signature (HMO) plan.
Important documents
- Evidence of Coverage (updated 9/20/22)
- List of Covered Drugs (updated 9/20/22)
- LIS Premium Summary chart (updated 10/2/22)
- Provider and Pharmacy directory (updated 10/21/22)
- Summary of Benefits (updated 9/20/22)
Member forms and information
- Auto Pay Form (updated 10/4/21)
- Care Management PHI Authorization Form (updated 11/12/21)
- Designated Personal Representative Form (updated 11/16/22)
- Member Rights and Responsibilities
- Prescription Reimbursement Form (updated 4/11/22)
Pharmacy Information
- List of Covered Drugs (updated 9/20/22)
- Prior Authorization Drug List (updated 10/12/22, under CMS review)
Here you can find important information regarding the 2023 WellSense Choice (HMO) plan.
Important documents
- Evidence of Coverage (updated 9/20/22)
- List of Covered Drugs (updated 9/20/22)
- LIS Premium Summary chart (updated 10/2/22)
- Provider and Pharmacy directory (updated 10/21/22)
- Summary of Benefits (updated 9/20/22)
Member forms and information
- Auto Pay Form (updated 10/4/21)
- Care Management PHI Authorization Form (updated 11/12/21)
- Designated Personal Representative Form (updated 11/16/22)
- Member Rights and Responsibilities
- Prescription Reimbursement Form (updated 4/11/22)
Pharmacy Information
- List of Covered Drugs (updated 9/20/22)
- Prior Authorization Drug List (updated 9/20/22, under CMS review)
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