Documents and Forms
Here you can find important information regarding the WellSense Added Value (HMO) plan.
Important documents
- Annual Notice of Change
- 2024 (updated 10/1/23)
- Evidence of Coverage
- List of Covered Drugs
- LIS Premium Summary chart
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 Reimbursement Form (updated 4/11/22)
- Release of Information Form / Formulario de divulgación de información (updated 7/6/23)
Pharmacy Information
Here you can find important information regarding the WellSense Signature (HMO) plan.
Important documents
- Annual Notice of Change
- 2024 (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 Reimbursement Form (updated 4/11/22)
- Release of Information Form / Formulario de divulgación de información (updated 7/6/23)
Pharmacy Information
Here you can find important information regarding the WellSense Choice (HMO) plan.
Important documents
- Annual Notice of Change
- 2024 (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 Reimbursement Form (updated 4/11/22)
- Release of Information Form / Formulario de divulgación de información (updated 7/6/23)
Pharmacy Information
Here you can find important information regarding the WellSense Premium Savings (HMO) plan.
Important documents
- Evidence of Coverage
- 2024 (updated 10/1/23)
- List of Covered Drugs
- 2024 (updated 10/2/23)
- LIS Premium Summary chart
- 2024 (updated 10/2/22)
- Provider and Pharmacy directory
- 2024 (updated 11/1/23)
- Summary of Benefits
- 2024 (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 Reimbursement Form (updated 4/11/22)
- Release of Information Form / Formulario de divulgación de información (updated 7/6/23)
Pharmacy Information
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