Documents and forms
- The Annual Notice of Change details any changes in the plan’s costs, coverage, or service area that will take effect the following January.
- The Evidence of Coverage provides the most detail about your health plan. This includes how the plan works, what’s covered, what’s not covered, the cost of services, and much more.
- The Summary of Benefits offers an overview of how you and your plan share the cost of covered healthcare services.
| Plan name | Annual Notice of Change | Evidence of Coverage | Summary of Benefits |
| WellSense Added Value (HMO) | 2024 | 2025 | 2024 | 2025 | 2024 | 2025 |
| WellSense Signature (HMO) | 2024 | 2025 | 2024 | 2025 | 2024 | 2025 |
| WellSense Choice (HMO) | 2024 | 2025 | 2024 | 2025 | 2024 | 2025 |
| WellSense Premium Savings (HMO) | 2025 | 2024 | 2025 | 2024 | 2025 |
| WellSense Signature Access (PPO) | 2025 | 2025 |
| List of covered drugs (updated 8/30/24) | Prior authorization drug list (updated 8/30/24) | |
| WellSense Added Value (HMO) | 2024 | 2025 | 2024 | 2025 |
| WellSense Signature (HMO) | 2024 | 2025 | 2024 | 2025 |
| WellSense Choice (HMO) | 2024 | 2025 | 2024 | 2025 |
| WellSense Premium Savings (HMO) | 2024 | 2025 | 2024 | 2025 |
| WellSense Signature Access (PPO) | | 2025 | | 2025 |
| Form name | English | Spanish | Last updated |
| Appointment of Representative form | English | ||
| Assign or Revoke a Personal Representative form | English | Spanish | 7/6/23 |
| Auto pay form | English | 10/4/21 | |
| Care Management PHI Authorization form | English | 11/12/21 | |
| Prescription Drug Reimbursement form | English | Spanish | 5/13/24 |
| Release of Information form | English | Spanish | 7/6/23 |
- LIS premium summary chart (updated 11/1/23)
- Member rights and responsibilities (updated 4/12/24)
- Provider and pharmacy directory (updated 9/9/24)
View and download important plan documents here.
Plan benefit documents
The Annual Notice of Change details any changes in the plan’s costs, coverage, or service area that will take effect the following January.
Last updated 10/1/23The Evidence of Coverage provides the most detail about your health plan. This includes how the plan works, what’s covered, what’s not covered, the cost of services, and much more.
- WellSense Added Value (HMO)
- WellSense Choice (HMO)
- WellSense Premium Savings (HMO)
- WellSense Signature (HMO)
The Summary of Benefits offers an overview of how you and your plan share the cost of covered healthcare services.
The Annual Notice of Change details any changes in the plan’s costs, coverage, or service area that will take effect the following January.
- WellSense Added Value (HMO)
- WellSense Choice (HMO)
- WellSense Premium Savings (HMO)
- WellSense Signature (HMO)
The Evidence of Coverage provides the most detail about your health plan. This includes how the plan works, what’s covered, what’s not covered, the cost of services, and much more.
- WellSense Added Value (HMO)
- WellSense Choice (HMO)
- WellSense Premium Savings (HMO)
- WellSense Signature (HMO)
- WellSense Signature Access (PPO)
The Summary of Benefits offers an overview of how you and your plan share the cost of covered healthcare services.
Pharmacy documents
List of covered drugs (updated 10/30/24)
- WellSense Added Value (HMO)
- WellSense Choice (HMO)
- WellSense Premium Savings (HMO)
- WellSense Signature (HMO)
Prior authorization drug list (updated 10/30/24)
List of covered drugs (updated 10/16/24)
- WellSense Added Value (HMO)
- WellSense Choice (HMO)
- WellSense Premium Savings (HMO)
- WellSense Signature (HMO)
- WellSense Signature Access (PPO)
Prior authorization drug list
- WellSense Added Value (HMO) - coming soon
- WellSense Choice (HMO) - coming soon
- WellSense Premium Savings (HMO)- coming soon
- WellSense Signature (HMO) - coming soon
- WellSense Signature Access (PPO)- coming soon
Member forms
- Appointment of Representative form
- Assign or Revoke a Personal Representative form (updated 7/6/23) | Spanish
- Auto pay form (updated 10/4/21)
- Care Management PHI Authorization form (updated 11/12/21)
- Prescription Drug Reimbursement form (updated 5/13/24) | Spanish
- Release of Information form (updated 7/6/23) | Spanish
- Release of Reproductive Healthcare Attestation form (updated 10/21/24)
Other documents
- LIS premium summary chart (updated 11/1/23)
- Member rights and responsibilities (updated 4/12/24)
- 2024 provider and pharmacy directory (updated 11/1/24)
- 2025 provider directory - HMO plans (updated 11/1/24)
- 2025 provider directory - PPO plans (updated 11/1/24)
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