Wellcare reimbursement form 2025

1. Click ‘Get Form’ to open the wellcare reimbursement form in the editor.
2. Begin by filling out the Member Information section. Enter your name, date of birth, ID number, street address, apartment/unit number, phone number, city, state, and zip code. Ensure all details are accurate for processing.
3. In the Reason for Request section, select one of the options that best describes your situation. If necessary, provide additional details in the space provided.
4. Next, complete the Pharmacy/Prescription Information section. Attach detailed prescription label receipts and fill in the required fields such as drug name, date of fill, quantity, day supply, amount paid, NDC, doctor’s name and NPI number.
5. Review all entries for clarity and accuracy. Sign and date the form at the bottom to certify that all information is correct.
6. Finally, submit your completed form along with any required receipts by mailing them to WellCare's Reimbursement Department at the address provided.

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