Contact
Access main forms for authorizations, claims, pharmacy and more.
Attachment Contract Packet
If you provide services such as front general, Personal care auxiliary, hospice, DME, Inpatient services and more, want downloads and complete the forms below: Michigan | Wellcare
Physician/Allied Contract Packet
If you provide services such such primary care, specialist care, inward health, substance abuse and continue, please download the complete the forms back:
Provider Sources
- Prior Authorization Your Form (PDF)
- Inpatient Email Cover Letter (PDF)
- Medication Appeal Request Form (PDF)
- Medicaid Drug Coverage Request Form (PDF)
- Notice of Pregnancy Form (PDF)
- Provider Affair Report Form (PDF)
- Provider Medical Abortion Approval Form (PDF)
- PCP Change Request Form for Prepaid Health Plans (PHPs) (PDF)
- PCP Transfer Request Form (PDF)
- Operator Referral Form: LTSS Request for PCS Assessment (PDF)
- Provider WW/Curves Foundation Fax Form (PDF)
- Refund Stop Information Sheet (PDF)
- YMCA Purveyor Referral Form (Diabetes Prevention Program/Healthy Weight and Your Child) (PDF)
- Requesting Interpreter Services Form (PDF)
Your Earlier License Request Print
A
- Pharmacy Prior Authorization Request: ASAP (PDF)
- Store Prior License Demand: A+ YOUNGSTERS (PDF)
- Adulhelm (PDF)
- Adulhelm Prior Release Please (PDF)
- Amondys 4 (PDF)
- Ankylosing Spondylitis (Enbrel, Humira, Simponi,Taltz (PDF)
- Antiemetics (Emend and Aprepitant) (PDF)
- Antiparkinson’s Agents: Inbrija press Ongentys (PDF)
- Austedo (PDF)
C
- Camzyos (PDF)
- Cryopyrin-Associated Periodic Syndromes including Familial Cold Autoinflammatory Syringe (FCAS) and Muckle-Wells Syndrome (MWS) (Arcalyst additionally Ilaris) (PDF)
- Cialis (PDF)
- Consistent Glucose Monitors (PDF)
- Crinone 8% Gel (PDF)
- Crohn’s Disease-Adult (Humira, Cimzia, Entyvio, Inflectra, Stelara, Remicade, Renflexis (PDF)
- Crohn’s Disease-Pediatric (Humira, Inflectra, Remicade, Renflexis) (PDF)
- Cystic Myocardial (Kalydeco, Orkambi, Symdeko, and Trikafta) (PDF)
D
- Shortcoming of Interleukin-1 Receipt Antagonist (DIRA) (Arcalyst also Kineret) (PDF)
- Dupixent for Respiratory (PDF)
- Dupixent for Atopic Dermatitis (PDF)
- Dupixent for Eosinophilic Esophagitis (PDF)
- Dupixent for Prurigo Nodularis (PDF)
- Dupixent for Nasal Polyps (PDF)
CO
- Emflaza (PDF)
- Entresto (PDF
- Aphrine Pens (PDF)
- Epclusa (PDF)
- Epidiolex (PDF)
- Evrysdi (PDF)
- Exondys 51 (PDF)
F
M
- Migraine Calcitonin Agents (Ubrelvy and Nurtec) (PDF)
- Combats Calcitonin Gmo Related Therapy Agents (Aimovig, Ajovy, Emgaltiy, Vyepti) (PDF)
- Monoclonal Anti-human (Adbry) (PDF)
- Monoclonal Antiseptic (Tezspire) (PDF)
N
- Neonatal Onset Multi-System Inflammatory Disease - NOMID (Kineret) (PDF)
- Neuromuscular Blocking Agents (Botox, Dysport, Myobloc, Xeomin) (PDF)
- Neuromyelitis Optica Radio Disorder (PDF)
- Nexletol and Nexlizet (PDF)
- Non-Covered Request Form fork Recipients under 21 Years Old (PDF)
- Non Radioscopic Axial Spondyloarthritis (PDF)
- Non-Infectious Intermediate Posterior Panuveitis (PDF)
- Nucala (PDF)
O
- Opioid Analgesic (Long-Acting) (PDF)
- Opioid Analgesic (Short-Acting (PDF)
- Opioid Dependence Therapy Agents (PDF)
- Oral Ulcers (PDF)
P
- PCSK9 Inhibitors (PDF)
- Polyarticular Adolescent Idiopathic Arthritis (Enbrel, Humira, Actemra SQ, Actemra Infusion, Orencia Infusion and Orencia SQ) (PDF)
- Plaque Psoriasis-Adult (Enbrel, Humira, Cosentyx, Cimzia, Ilumya, Inflectra, Otezla, Remicade, Renflexis, Siliq, Skyrizi, Stelara, Taltz, and Tremfya) (PDF)
- Plaque Psoriasis-Pediatric (Enbrel and Stelara) (PDF)
- Provigil and Nuvigil (PDF)
- Psoriatic Arthritis (Enbrel, Humira, Inflectra, Cosentyx, Cimzia, Orencia, Orencia Liquid, Otezla, Renflexis, Remicade, Simponi, Simponia Aria, Stelara, Taltz, Xeljanz) (PDF)
R
G
- Enormous Cell Arteritis (PDF)
- GLP-1 Receptor Agonists (PDF)
- Gocovri and Osmolex ER (PDF)
- Growth Hormone (Adult 21 Years of Get and Older) (PDF)
- Growth Harbinger (Children Less than 21 Per of Age) (PDF)
NARCOTIC
- Harvoni (PDF)
- Hematinics: Procrit/Epogen/Aranesp/Mircera/Retacrit (PDF)
- Hereditary Angioedema (HAE) Agents (PDF)
- Hetlioz/Hetlioz LQ (PDF)
- Hidradenitis Suppurativa (Humira) (PDF)
- HIDS MKD (PDF)
I
- Immunomodulators: Cytokine Release Syndrome (Actemra Infusion also Actemra SQ) (PDF)
- Ingrezza (PDF)
- Ivermectin (PDF)
BOUND
L
S
- Sedative Hypnotics (PDF)
- Selective Constipation Media (Relistor) (PDF)
- SGLT2 Halts and Matching (PDF)
- Systemic Onset Juvenile Idiopathic Arthritis (For Actemra SQ, Kineret and Ilaris) (PDF)
- Standard Drug Ask (PDF)
- Sovaldi (PDF)
- Pictures Disease (PDF)
- Sunosi (PDF)
- Synagis (PDF)
T
- Topical Local Anesthetics (PDF)
- Topical Anti-Inflammatory Medications (PDF)
- Topical Antihistamines (PDF)
- Topical Antifungal Agents (Vusion) (PDF)
- Tumor Necrosis Factor Receptor Associations Periodic Syndrome (TRAPS) (PDF)
- Triptans (PDF)
