Member resources

From provider directories to forms and coverage details, find what you need to help get the most out of your health plan. Looking for a specific form or information on prescription drugs? See our most requested links.

Most requested links

Prescription drug info

Plan information

Find the information you need to use your health plan with confidence, from coverage details to provider search tools and preventive care resources.

Coverage manual and Summary of Benefits (SBC) Finder

Search for the Summary of Benefits and Coverage (SBC) and coverage manual for your plan.

Provider directory

Search for in-network providers for your Wellmark plan.

Preventive Services List

Learn more about preventive care visits, which may be at no cost to you, as required by the Affordable Care Act (ACA).

Prescription drugs and pharmacy information

Get the information you need to make the most of your pharmacy benefits. See what drugs are covered, learn more about specialty drugs or find a pharmacy that fits your needs.

Formulary drug lists

See if a drug is covered under your plan, whether it needs special approval and coverage limits.

PrudentRx Drug List

Enroll to save on select specialty drugs.

Specialty Drugs

Some prescription medications require special handling, administration or monitoring. Specialty prescription coverage is based on your health plan benefit.

Pharmacy Finder

Find a local retail pharmacy in your area to fulfill all your prescription needs.

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Transparency information

Access tools that help you understand health care costs, connect to your health plan information and learn about your rights as a member.

Machine Readable Files

Files providing pricing data for covered items and services based on in-network rates, historical out-of-network allowed amounts and prescription drug rates and costs.

Cost Tool

Research cost estimates for items and services covered by your plan.

Developer – Interoperability API

Learn more about the technical requirements to access Wellmark's Interoperability APIs for payer-to-payer API, provider access API, prior authorization API and for 3rd party apps for patient access API.

QHP Transparency

Learn more about data sharing tools and options for members enrolled in QHP coverage.

No Surprises Act Notice

Your rights and protections against surprise medical bills.

Authorizations and approvals

Learn when prior authorization is required for medical services and prescription drugs, and review the policies and criteria used to make coverage decisions.

Medical and drug authorizations

Find out what items and services require prior approval or prior authorization.

Criteria or Medical Policy used to make Prior Approval determinations

Find out what items or services require prior approval or prior authorization and find the criteria we use to make determinations.

Medical Authorization Tables

The medical authorization table is your best resource for viewing medical policies and criteria used by Wellmark. It is also your first stop in learning whether an authorization is required.

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Member forms

Appeal forms

These forms should be completed if you disagree with a benefit determination and request a review of a claim for benefits.

Member appeal forms

Personal Representative Appointment and Authorization to Release Protected Health Information

Appoint an individual, such as a caregiver or provider, to submit claims or appeals on your behalf.

Personal Representative Appointment and Authorization to Release Protected Health Information

Claim form

Member-submitted claim form.

Claim form

Discrimination Complaint form

Form to report discrimination in violation of section 1557 of the ACA, which prohibits discrimination on the basis of race, color, national origin, sex, age or disability in certain health programs and activities

Discrimination Complaint Form

HIPAA Authorization

Form used to authorize Wellmark to disclosure protected health information.

HIPAA Authorization

Formulary Exception Request Form

In the event CVS denies the exception request, you or your doctor may request an Independent Review by an Independent Review Organization (IRO).

Formulary Exception Request Form

Tax Information for Members

Learn more about important health coverage tax documents.

Tax Information for Members
Medicare Advantage forms

Medicare Advantage Patient Access API

Find out what items and services require prior approval or prior authorization.

The medical authorization table is your best resource for viewing medical policies and criteria used by Wellmark. It is also your first stop in learning whether an authorization is required.

CMS Medicare Complain Form

File a complaint with CMS regarding your MA plan.

CMS Medicare Complaint Form

MA Report Fraud

Report suspected fraud. Wellmark Advantage Health Plan maintains a policy that enforces non-retaliation and non-intimidation against those who report potential concerns.

MA Report Fraud

MA Code of Business Conduct

The Code spells out the high ethical and legal standards of business conduct we follow and is intended to provide a framework for good decision making.

MA Code of Business Conduct

MA Provider Finder

Explore available care options based on your plan type and locate a provider in your network.

MA Provider Finder

MA Formulary Drug List

Confirm that the prescriptions you take are in the Plan’s formulary.

MA Formulary Drug List

Appointment of Representation Form

Use this form if you choose to have a relative, friend, attorney, physician or other advocate serve as your Medicare representative.

Appointment of Representation Form