Documents and forms

View and download important plan documents here.

Plan benefit documents

The Annual Notice of Change details any changes in the plan’s costs, coverage, or service area that will take effect the following January.

• WellSense Added Value (HMO)
• WellSense Choice (HMO)   
• WellSense Premium Savings (HMO)
• WellSense Signature (HMO)

Updated 11/19/24

The Evidence of Coverage provides the most detail about your health plan. This includes how the plan works, what’s covered, what’s not covered, the cost of services, which services require prior authorization, and much more.

• WellSense Added Value (HMO)
• WellSense Choice (HMO)   
• WellSense Premium Savings (HMO)
• WellSense Signature (HMO)
• WellSense Signature Access (PPO)

Updated 10/1/24

The Summary of Benefits offers an overview of how you and your plan share the cost of covered healthcare services.

Pharmacy documents

List of covered drugs 

• WellSense Added Value (HMO)  
• WellSense Choice (HMO)  
• WellSense Premium Savings (HMO) 
• WellSense Signature (HMO)
• WellSense Signature Access (PPO)

Prior authorization drug list 

• 2025 prior authorization drug list
  

Member forms

• Appointment of Representative form
• Assign or Revoke a Personal Representative form (updated 7/6/23)   |   Spanish
• Auto pay form (updated 10/4/21)
• Care Management PHI Authorization form (updated 11/12/21)
• Release of Information form (updated 7/6/23)   |   Spanish
• Release of Reproductive Healthcare Attestation form (updated 10/21/24)

• Medical reimbursement form (updated 3/4/25)
• Northeast Delta Dental Reimbursement Form
  Use this form if you need to be reimbursed for seeing an out-of-network Northeast Delta Dental provider.  WellSense Signature Access (PPO) plan only.
• OTC reimbursement form (updated 1/24/25)
  Request reimbursement for eligible OTC and health-related items that you purchased at a participating retailer.
• Prescription drug reimbursement form (updated 5/13/24)   |   Spanish
• Vision debit card reimbursement form (updated 1/24/25)
  Request reimbursement for vision services and hardware. WellSense Added Value and WellSense Choice plans only.
• VSP reimbursement form (updated 1/24/25)
  Use this form if you need to be reimbursed for seeing an out-of-network VSP provider. WellSense Signature Access (PPO) plan only.

Other documents

• LIS premium summary chart (updated 9/25/24)
• Member rights and responsibilities (updated 4/12/24)
• 2025 pharmacy directory (updated 4/30/25)
• 2025 provider directory - HMO plans (updated 4/30/25)
• 2025 provider directory - PPO plans (updated 4/30/25)
• 2025 dental procedure codes - HMO and PPO plans (updated 5/2/25)