2024 Forms and resources
Browse all Blue Medicare AdvantageSM HMO and PPO plan materials, forms, documents and resources.
Provider Directory External Site
Find a primary care provider, specialist, hospital, specialty facility, or medical equipment provider.
Pharmacy Directory External Site
Find a local pharmacy in your area or a retail pharmacy online to fulfill your prescription drug needs.
Drug List (Formulary) External Site
Check to see if the prescription drugs you take on a regular basis are covered under your plan.
2024 Plan benefit details
- Summary of Benefits – View key features of the plans available in your state.
- Evidence of Coverage – Learn more about in-depth coverage details.
- Iowa Blue Medicare Advantage HMO Evidence of Coverage PDF File
- Iowa Blue Medicare Advantage PPO and Enhanced PPO Evidence of Coverage PDF File
- Iowa Blue Medicare Advantage PPO | Avera Evidence of Coverage PDF File
- Iowa Blue Medicare Advantage Valor PPO Evidence of Coverage PDF File
- South Dakota Blue Medicare Advantage PPO and Enhanced PPO Evidence of Coverage PDF File
- South Dakota Blue Medicare Advantage PPO | Avera Evidence of Coverage PDF File
- South Dakota Blue Medicare Advantage Valor PPO Evidence of Coverage PDF File
- Medicare Part B Drug Addendum PDF File
- Provider directories – Use our online tool or download and print a provider directory.
- Search online External Site
- Download a PDF directory External Site PDF Provider Directories
- Request a print directory be mailed to you
- Annual Notice of Change
- Iowa Blue Medicare Advantage HMO Annual Notice of Change PDF File
- Iowa Blue Medicare Advantage PPO Annual Notice of Change PDF File
- Iowa Blue Medicare Advantage Enhanced PPO Annual Notice of Change PDF File
- Iowa Blue Medicare Advantage Valor PPO Annual Notice of Change PDF File
- Iowa Blue Medicare Advantage PPO | Avera Annual Notice of Change PDF File
- South Dakota Blue Medicare Advantage PPO Annual Notice of Change PDF File
- South Dakota Blue Medicare Advantage Enhanced PPO Annual Notice of Change PDF File
- South Dakota Blue Medicare Advantage Valor PPO Annual Notice of Change PDF File
- South Dakota Blue Medicare Advantage PPO | Avera Annual Notice of Change PDF File
- Reimbursement forms – Use these forms if you need to be reimbursed for payments made directly to your provider.
- Member claims reimbursement PDF File
- Pharmacy reimbursement PDF File
- Dental reimbursement for Iowa and South Dakota: create a Delta Dental® account External Site to access
- Vision reimbursement PDF File
- International claims reimbursement PDF File
- Authorization agreement for automatic premium withdrawal – Have your Medicare plan payment automatically deducted from your bank each month.
- Blue Medicare Advantage HMO Authorization Agreement PDF File
- Blue Medicare Advantage PPO, Enhanced PPO, and Avera PPO Authorization Agreement PDF File
- Medicare Advantage paper enrollment form – Print, fill out and mail this paper application. For faster, easier enrollment, enroll online or call (TTY: 711).
- Star ratings flyer – Every year, Medicare evaluates plans based on a 5-star rating system.
- Blue Medicare Advantage HMO Star Ratings Flyer PDF File
- Blue Medicare Advantage PPO and Enhanced PPO Star Ratings Flyer PDF File
- Pre-enrollment checklist – Use this checklist to make sure you understand your benefits and important rules before enrolling in a plan.
Customer Service
Wellmark Advantage Health Plan HMO Member Services Phone: (TTY: 711)
Wellmark Advantage Health Plan PPO Member Services Phone: (TTY: 711)
Member pharmacy resources
- Drug List (formulary) – Use our online tool External Site or download and print a drug list formulary directory.
- Iowa Blue Medicare Advantage HMO Drug List PDF File
- Iowa Blue Medicare Advantage PPO and Enhanced PPO Drug List PDF File
- Iowa Blue Medicare Advantage PPO | Avera Drug List PDF File
- South Dakota Blue Medicare Advantage PPO and Enhanced PPO Drug List PDF File
- South Dakota Blue Medicare Advantage PPO | Avera Drug List PDF File
- Pharmacy directories – Use our online tool External Site or download and print a pharmacy directory.
- Iowa Blue Medicare Advantage HMO directory Pharmacy Directory PDF File
- Iowa Blue Medicare Advantage PPO, Avera PPO and Enhanced PPO directory Pharmacy Directory PDF File
- South Dakota Blue Medicare Advantage PPO, Enhanced PPO and Avera PPO directory Pharmacy Directory PDF File
- Request a print directory be mailed to you
- Mail order drug form PDF File – Complete this form to receive your prescriptions by mail.
- Pharmacy reimbursement form PDF File – Request reimbursement for certain prescription drug purchases.
- Comprehensive Drug List (Formulary) Prior Authorization/Step Therapy Program PDF File – This list shows all of the drugs that require prior authorization or are part of our step therapy program.
- Low Income Subsidy (LIS) Premium Summary Prescription Drug Premium Chart – If you qualify for extra help paying for prescription drug coverage, you can use these charts to find out what you'll pay each month for our plans.
- Part D determination and redetermination request forms – Use these forms to request a coverage decision if you take a drug that is not covered by our plan or if you are appealing a previously denied coverage decision.
- Blue Medicare Advantage HMO and PPO coverage determination form PDF File
- Blue Medicare Advantage HMO request for redetermination form PDF File
- Blue Medicare Advantage PPO, Enhanced PPO, and Avera PPO request for redetermination form PDF File
- Prescription drug tracker PDF File – Keep track your current prescriptions and share this information with any health care professionals you see.
Pharmacy Questions
Wellmark Advantage Health Plan HMO Pharmacy Services Phone: (TTY: 711)
Wellmark Advantage Health Plan PPO Pharmacy Services Phone: (TTY: 711)
Health care fraud is a serious business in the U.S. — and is a serious crime.
There are many different kinds of health care fraud. Common examples include:
- Using an expired or fraudulent identification card to get medical services or medications.
- Lending an ID card to someone who isn't entitled to it.
- Adding someone who isn't eligible for coverage to a contract.
- Billing for services never received.
- Performing medically unnecessary services to receive payment from insurers.
- Billing for more expensive services or procedures than were actually provided.
- Accepting kickbacks for patient referrals.
You can report suspected wrongdoing confidentially in any of the following ways:
- Call our confidential Fraud Hotline at (TTY:711) from 7:30 a.m. to 3:30 p.m., Monday through Friday. After hours calls will be recorded. A fraud specialist will return your call the next business day to collect further information.
- Email us at stopfraud@wellmarkadvantagehealthplan.com Send Email. Please note that the information you submit isn't secure or encrypted.
You may remain anonymous. All information we receive is strictly confidential. If you'd like a response from us about your report, please include your contact information.
Wellmark Advantage Health Plan maintains a policy that enforces non-retaliation and non-intimidation against those who report potential concerns.
In the event the Governor of your state, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in your geographic area, be assured that Wellmark Advantage Health Plan will continue to provide benefits based on the plan you are enrolled in. You will still be able to visit your doctor, urgent care facility or hospital if needed. Generally, during a disaster, your plan will allow you to obtain care from out-of-network providers at in-network rates. Our website will be updated if a disaster or public health emergency has occurred.
Did you know that federal law empowers you with certain rights when it comes to your health care? Here’s what is required of us.
We must:
- Treat you with fairness and respect at all times.
- Ensure that you get timely access to your covered services and drugs.
- Protect the privacy of your personal health information.
- Give you information about your plan, the providers in your network and the services covered.
- Provide information in a way that works for you. For example, we have translation services for customers who speak English as their second language. TTY users should call 711.
You have the right to:
- Know your treatment options and participate in decisions about your health care.
- Give instructions about what happens if you’re unable to make medical decisions for yourself.
- Make complaints and ask us to reconsider decisions we’ve made.
- File a grievance about anything from your doctor's office cleanliness to how we've handled certain situations.
If you feel your rights haven’t been protected, or if you have any questions, please call the number on the back of your Wellmark Advantage Health Plan ID card.
You can also get help with your rights and protections from the Medicare Beneficiary Ombudsman External Site, a person who reviews and helps you with your Medicare complaints.
As a member of one of our plans, you also have some responsibilities. These include:
- Paying your monthly premium(s).
- Telling us your new address if you move.
- Familiarizing yourself with the services that are covered under your plan.
- Telling us if you have any other health insurance coverage or prescription drug coverage besides our plan. We’re here to help you coordinate the health and drug benefits you get from our plan with any other benefits available to you.
If you have any questions, we’re here to help. Just call the customer service number on the back of your Wellmark Advantage Health Plan ID card.
We're available from 8 a.m. to 8 p.m. local time, Monday through Friday, with additional weekend hours Oct. 1 through March 31.
- Customer Service for Wellmark Advantage Health Plan HMO: (TTY: 711)
- Customer Service for Wellmark Advantage Health Plan PPO: (TTY: 711)
When you want to ask your plan to cover or share the cost of a medical service or drug, you can ask for a coverage decision on medical services or a coverage determination on prescription drugs.
Who can ask for a coverage decision?
In most cases your doctor will contact us, but you or a representative can also ask for a coverage decision. (To appoint a representative, use the Appointment of Representative form External Site.)
How long does a coverage decision take?
If your coverage decision is related to a medical service you haven't received yet, we’ll reply within 14 days. If your coverage decision is related to prescription drugs you haven't received yet, we’ll reply within 72 hours.
What if I can’t wait that long?
You, your doctor or your Appointment of Representative can request a fast coverage decision in the following cases:
- Waiting could cause serious harm to your health or hurt your ability to function.
- You’re asking for a coverage decision about medical care or a prescription drug you haven’t received yet.
For a fast coverage decision, we will reply within 72 hours for a medical service and 24 hours for a prescription drug determination.
How do I ask for a coverage decision?
Medical Service Coverage Decision
For medical, start with your doctor. If you do have to get involved, call the customer service number on the back of your Wellmark Advantage Health Plan ID card.
We're available from 8 a.m. to 8 p.m. local time, Monday through Friday, with additional weekend hours Oct. 1 through March 31.
- Customer Service for Wellmark Advantage Health Plan HMO: (TTY: 711)
- Customer Service for Wellmark Advantage Health Plan PPO: (TTY: 711)
You can also request a coverage decision by asking your doctor to write down a description of the service, why you need it and any other information, then mailing or faxing to:
Wellmark Advantage Health Plan Appeals & Grievances
P.O. Box 211483
Eagan, MN 55121
Fax: 1-866-533-6950
Drug Coverage Determination
The most common reasons someone asks for a drug coverage determination include:
- If you want to ask your plan to cover a prescription drug or change how a drug is covered.
- If you want a tier exception to lower your copay for a Tier 2 or Tier 4 drug.
- If you want an exception to the step therapy, prior authorization, quantity limit or other requirements we have for a drug.
You can find information about tiers, step therapy, prior authorization and more by looking in your plan's drug list, also called a formulary.
If you want to talk to us about a coverage determination for a drug, start by giving us a call.
Call 24 hours a day, 7 days a week:
- Pharmacy Services for Wellmark Advantage Health Plan HMO: (TTY: 711)
- Pharmacy Services for Wellmark Advantage Health Plan PPO: (TTY: 711)
You can also request a coverage determination by submitting a prescription coverage determination form PDF File, writing a letter, or sending a fax.
CVS Caremark Prior Authorization P.O. Box 52000, MC109Phoenix, AZ 85072-2000
Fax: 1-855-633-7673
As a Medicare Advantage member, you can always call us when you have a question, concern or complaint about your plan. But for some situations, we have a formal complaint process in place. When you contact us with your complaint, it's also called filing a grievance.
Concerns related to any of these items are considered complaints:
- Quality of care
- Your right to privacy
- Poor customer service
- Long waiting times for appointments, on the phone, at your doctor’s office, etc.
- Information you get from us
- How long we take to respond to a coverage decision or appeal
You can find more information about complaints in your plan's Evidence of Coverage.
Additional things to know about complaints:
- Medicare guidelines give you 60 days to tell us after the problem occurs.
- You can’t be disenrolled from your plan for contacting us with a complaint.
- Your complaint will always be handled fairly and investigated following Medicare rules.
Medical Grievances
To contact us about a complaint related to medical services or treatment, it’s often easiest to call the customer service number on the back of your Wellmark Advantage Health Plan ID card.
We're available from 8 a.m. to 8 p.m. local time, Monday through Friday, with additional weekend hours Oct. 1 through March 31.
- Customer Service for Wellmark Advantage Health Plan HMO: (TTY: 711)
- Customer Service for Wellmark Advantage Health Plan PPO: (TTY: 711)
You can also start your grievance by writing a letter or sending a fax using the contact information below.
Wellmark Advantage Health Plan Appeals & GrievanceP.O. Box 211483Eagan, MN 55121
Fax: 1-866-533-6950
Pharmacy Grievances
To contact us about a complaint related to pharmacy services or treatment, it’s often easiest to call the Pharmacy Services number on the back of your Wellmark Advantage Health Plan ID card.
Phone: Call 24 hours a day, 7 days a week:
- Pharmacy Services for Wellmark Advantage Health Plan HMO: (TTY: 711)
- Pharmacy Services for Wellmark Advantage Health Plan PPO: (TTY: 711)
You may also send a request by writing a letter or sending a fax using the contact information below.
CVS Caremark Medicare Part D Grievance Department P.O. Box 30016Pittsburgh, PA 15222-0330
Fax: 1-866-217-3353
Tip: You can also contact Medicare directly about a complaint by using this online complaint form External Site.
Sometimes you or your doctor may ask your plan to cover something it doesn’t already cover. Or you might ask us to cover a service or drug differently or change what we pay for it. When that happens, we have to make what’s called a coverage decision. When we notify you about our decision, you may not agree with it.
If this happens, you can appeal. That’s asking us to review your request again and change our decision. You can always talk to us about an appeal by calling the customer service number on the back of your Wellmark Advantage Health Plan ID card.
Here’s an overview of what you need to know about appeals, and other ways to contact us about an appeal when you have a Medicare Advantage plan. You can find more information about appeals in your plan's Evidence of Coverage.
How long do I have to appeal a decision?
Medicare guidelines give you 60 days to contact us about an appeal after you get our written notification. We may give you more time in some cases, for example if you’re very ill.
Who can appeal a decision?
You or your doctor can start an appeal. A representative — someone other than your doctor acting on your behalf — can also appeal a decision for you, as long as you fill out and send us an Appointment of Representative form External Site. We won’t be able to complete the appeal process without it.
How long will it take to hear from us about an appeal?
- It depends on what you’re appealing.
- If your appeal is related to a medical service you're waiting to receive, we'll reply within 30 days.
- If your appeal is related to prescription drugs, we'll reply within seven days.
- If your appeal is related to payment for prescription drugs you've already paid for, we'll reply within 14 days.
- If your appeal is related to a medical service you've already received, or payment for a medical service you've already paid for, we'll reply within 60 days.
What if I can’t wait that long?
You can ask for a fast appeal when you’re appealing a decision about medical care or a prescription drug you haven’t received yet. If waiting could cause serious harm to your health or hurt your ability to function, you’ll hear from us within 72 hours.
Your doctor should request a fast appeal.
Medical Appeals
To contact us about an appeal related to medical services or treatment, it’s often easiest to call the customer service number on the back of your Wellmark Advantage Health Plan ID card.
We're available 8 a.m. to 8 p.m. local time, Monday through Friday, with additional weekend hours Oct. 1 through March 31.
- Customer Service for Wellmark Advantage Health Plan HMO: (TTY: 711)
- Customer Service for Wellmark Advantage Health Plan PPO: TTY: 711)
If you choose to start your appeal by sending in a letter or fax. Please describe what you would like to appeal and, if possible, include a copy of the letter you received from us. Include your name, member ID, a daytime telephone number and signature.
Wellmark Advantage Health Plan Appeals & Grievances
P.O. Box 211483
Eagan, MN 55121
Fax: 1-866-533-6950
Pharmacy Appeals
To contact us about an appeal related to pharmacy services or treatment, it’s often easiest to call the Pharmacy Services number on the back of your Wellmark Advantage Health Plan ID card.
Phone: Call 24 hours a day, 7 days a week:
- Pharmacy Services for Wellmark Advantage Health Plan HMO: (TTY: 711)
- Pharmacy Services for Wellmark Advantage Health Plan PPO: (TTY: 711)
You may send a request by filling out a Redetermination Request Form:
- Redetermination Request form for Wellmark Advantage Health Plan HMO PDF File
- Redetermination Request form for Wellmark Advantage Health Plan PPO PDF File
You may also write a letter or send a fax using the contact information.
CVS Caremark Part D AppealsP.O. Box 52000, MC109Phoenix, AZ 85072-2000
Fax: 1-855-633-7673
You may choose to have a relative, friend, attorney, physician or other advocate serve as your Medicare representative.
First, you and your representative need to download and fill out an Appointment of Representative form External Site.
How to complete the Appointment of Representative form
Please print or type your full name and Medicare number. If you appoint more than one person, you’ll need to fill out a form for each person.
Section 1: Appointment of Representative: Give the name and address of the person you're appointing. You may list one or more persons in an organization, but not the organization itself. Sign and date this section as the "Party Seeking Representation" and provide your street address and phone number.
Section 2: Acceptance of Appointment: Your representative fills out this section. He or she must give his or her name, sign and date the form, and provide his or her street address and phone number.
Section 3: Waiver of Fee for Representation: Completing this portion of the form means your representative won't charge a fee to represent you. If your representative is a health care provider, he or she is required to list your name, sign and date this section.
Section 4: Waiver of Payment for Items or Services at Issue: If your representative is a health care provider, he or she must sign and date this section. Doing so means you won’t be billed for items or services your plan doesn’t cover if they’re submitted on your behalf.
Where to send the Appointment of Representative form
If your representative will represent you in medical matters with Wellmark Advantage Health Plan, mail the form to:
Wellmark Advantage Health Plan Appeals & Grievances
P.O. Box 211483
Eagan, MN 55121
If your representative will assist you in prescription drug matters with Wellmark Advantage Health Plan, mail or fax the form to:
CVS Caremark Medicare Coverage Determinations and AppealsP.O. Box 52000, MC 109Phoenix, AZ 85072
Fax #: 1-855-633-7673
If you're not happy with the Medicare Advantage plan you chose, there are certain times of the year you can select a new one.
Annual Enrollment Period (AEP)
AEP happens between Oct. 15 and Dec. 7 every year. This is the time when you can add a new Medicare Advantage plan, choose a different Medicare Advantage plan, or drop Medicare Advantage altogether and use Original Medicare only. Any changes take effect on Jan. 1.
Open Enrollment Period (OEP)
The annual OEP is for people who enrolled in Medicare Advantage but have changed their mind. OEP happens every year between Jan. 1 and March 31. During OEP, you can drop Medicare Advantage altogether, use Original Medicare for health coverage with an additional prescription drug plan. Cancellation of a Medicare Advantage plan during this time takes effect the first day of the month after we get your cancellation request. If you choose to enroll in a Medicare prescription drug plan, that plan membership begins at the same time.
Special Enrollment Period (SEP)
An SEP is for people who qualify to change plans outside of the traditional enrollment and disenrollment periods, like if you move outside your plan's coverage area or are newly eligible for Extra Help with Medicare prescription coverage. During this period, you can change to another Medicare Advantage plan with or without a prescription drug plan or change to Original Medicare with or without a prescription drug plan. Changes during this time period take effect the first day of the month after we receive your request to change your plan.
Tip: It might take time before your new coverage starts. So, until your membership with us ends, you'll need to keep getting your medical services and drugs through our plan.
Your rights and responsibilities when you leave our plan
When you leave one of our plans, there are laws around what we need to do for you, and what you need to do for us.
We need to:
- Process all eligible plan cancellation requests.
- End your membership when the government asks us to.
- Give you a list of reasons in writing if we ask you to leave our plan.
You'll need to pay any outstanding balances you owe us.
If you think we've violated your rights, you can file a complaint with us or with the government.
Want more information?
If you have more questions about leaving our plan, call the customer service number on the back of your Wellmark Advantage Health Plan ID card.
We're available from 8 a.m. to 8 p.m. local time, Monday through Friday, with additional weekend hours Oct. 1 through March 31.
- Customer Service for Wellmark Advantage Health Plan HMO: (TTY: 711)
- Customer Service for Wellmark Advantage Health Plan PPO: (TTY: 711)
We are committed to protecting your health information. Read our privacy notice under the HIPAA Privacy Rule.
If you would further like to manage your protected health information, you can use the following forms:
- Privacy Notice under the HIPAA Privacy Rule PDF File
- Member consent for release of protected health information PDF File
- Authorization to revoke a previous authorization PDF File
- Request for access to designated protected health information records PDF File
- Request to amend protected health information PDF File
- Request for restriction of use and disclosure of protected health information PDF File
- Request for confidential communications PDF File
- Update method of confidential communications PDF File
- Cancel confidential communications PDF File
- Request for list of disclosures of protected health information PDF File
- Affidavit of next of kin PDF File
- Health care privacy practices complaint form PDF File
Provider Forms and Resources
Medical
Drug list
- Iowa Blue Medicare Advantage HMO Provider Drug List PDF File
- Iowa Blue Medicare Advantage PPO and Enhanced PPO Provider Drug List PDF File
- Iowa Blue Medicare Advantage PPO | Avera Provider Drug List PDF File
- South Dakota Blue Medicare Advantage PPO and Enhanced PPO Provider Drug List PDF File
- South Dakota Blue Medicare Advantage PPO | Avera Provider Drug List PDF File
Part B Drug
Part D Drug
Provider Services
Provider services/inquiries Phone: | Fax: 1-866-530-0102
Medical authorization requests Phone: | Fax: 1-866-313-8595
Additional Medicare Advantage Provider resources
Other pharmacies are available in our network.
Delta Dental® is an independent company providing dental administrative services on behalf of Wellmark Advantage Health Plan, Inc.
