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Wellcare Value Script (PDP)

ᎢᎩᏓ
ᎦᎴᏴᏙᏗ

ᎠᎩᏍᏗ ᎤᏴᏍᏗ ᏕᎦᏅᏅᏛ (ᏂᏕᎬᏅ ᎢᏗᎬᏁᏗ ᏗᎦᏟᏌᏅᎯ) ᎠᎴ ᏐᎢ ᏗᎪᏪᎳᏅᎢ

ᏣᎮᏍᏗ ᏗᏣᏓᏛᏗ ᏄᏰᎵᏛ ᎢᏳᏍᏗ ᏅᏬᏘᏃ ᎨᏒᎢ ᎠᏚᏓᎸᏙᏗ ᎬᏗ ᏣᏤᎵ ᎠᏍᏓᏩᏛᏍᏗ? ᎠᏴᏍᏗ ᏣᏤᎵ ᏂᏕᎬᏅᎢ ᏂᏗᎬᏁᏗ ᏕᎦᏟᏌᎲᎢ ᎠᏂ ᎠᎴᏃ ᎠᏱᏍᏗ ᎠᎩᏍᏗ ᎤᏴᏍᏗ ᎤᎶᏒ ᎾᏍᎩ ᎠᏱᏍᏗ ᎬᏔᏂᏓᏍᏗ.

ᎠᎩᏍᏗ ᎤᏴᏍᏗ ᎠᏱᏍᏗ ᎬᏔᏂᏓᏍᏗ

ᎠᏱᏍᏗ ᎠᎩᏍᏗ ᎤᏴᏍᏗ ᎤᎶᏒ ᎾᏍᎩ ᎠᏱᏍᏗ ᎬᏔᏂᏓᏍᏗ

ᎠᎩᏍᏗ ᎤᏴᏍᏗ ᏕᎦᏅᏛᎢ ᎠᎴ ᏗᎪᏪᎳᏅᎢ

ᏯᏘᎾ ᏱᎬᎾᏕᎾ ᏂᏕᎬᏅ ᎢᏗᎬᏁᏗ ᏗᎦᏟᏌᏅᎯ

ᎠᏓᏃᎯᏎᎯ ᎦᏁᏟᏴᏍᏗ

ᎤᏓᎷᎸᎢ ᎠᎵᏍᎪᎸᏗᏍᎩ

ᎠᎳᏍᎬᏓ ᏗᎨᏥᏅᏬᏗ

ᏅᏬᏘ ᎤᏂᏍᏆᏂᎪᏙᏗ ᏗᎧᎵᎢᏍᏗ

ᎯᎧᎵᏏᏍᏌ ᎯᎠ ᎠᎧᎵᏏᏐᏗ ᎾᎢ ᎠᏔᏲᏍᏗ ᏂᎦᏓ ᎨᎦᏈᏴᎡᏓ ᎾᏍᎩᎾ ᏣᏚᏓᎸᏛᎢᎠᏓᏅᏍᏙᏗ ᏗᎩᏍᏗ ᏧᏴᏍᏗ ᎾᏍᎩᎾᎢ ᏂᎯ ᏣᏈᏴᏓ ᎧᎵᎢ ᏓᎬᏩᎶᏛᎢ ᎾᏍᎩᎾᎢ.

Members can complete this form to order prescriptions from Express Scripts® Pharmacy.

Preferred diabetes testing supplies list (blood glucose meters and test strips) you can receive from an in-network pharmacy for plan years 2024 and 2025.

ᎯᎠ ᎪᏪᎳᏅᎢ ᏓᏍᏓᏅᏃᏛᎢ ᏣᏤᎵ ᏄᏓᎴᏒ ᏗᏣᏤᎵᎦᏯ ᎬᏗ ᏗᎬᏩᎵ ᎾᎢ ᏣᏤᎵ Medicare ᎠᎩᏍᏗ ᎤᏴᏍᏗ ᎠᏍᏓᏩᏛᏍᏗ.

Complete this printable form to ask us for a decision about a prescription drug and your specific plan coverage. Members should fax form to 1-866-388-1767.

Complete this printable form to ask for an appeal after being denied a request for coverage or payment for a prescription drug. Members should fax form to 1-866-388-1766.

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Y0020_WCM_134133E_M Last Updated On: 8/15/2023
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