These forms, excluding the W-9 form, can be completed online. Then you can print, sign and send to Wellmark for processing. Note: To avoid delays in processing your application or contract, please access updated documents using the links below. Please dispose of any paper stockpile you may have. Wellmark’s contracts have been updated to reflect a change in signature authority, while other addendums or applications now request additional information.
A non-formulary drug is a drug that is not covered under a prescription drug plan because cost-effective alternatives are available under the formulary drug coverage.
If you need to prescribe a non-formulary medication, complete the Exception Request form and fax it to the number on the form.
Note: This form is different than a prior authorization request, which allows Wellmark to verify a prescription drug is part of a specific treatment plan and is medically necessary.
The following forms can be completed online, but you must print and fax the forms to 1-866-884-4345.
*View the medical policies associated with these drugs.
Learn more about the provider post-service appeal process.
Note: The post-service provider appeal process does not apply to overpayment recovery requests. If you have received an overpayment recovery request and do not agree with our reasons for requesting the refund, submit an overpayment recovery appeal.
To order a large supply of forms or to order materials not listed on this page, use the Provider Forms Order Form.