Forms and Documents for Brokers

All forms are in Adobe Acrobat format.

Directories:

• Broker Directory
• Contact Phone List

General:

• Broker Commissions Authorization/Agreement for Direct Deposit
• Commercial Table of Commissions
• Presbyterian Senior Care Table of Commission Rates
• How to Quote and Enroll a  Group with Presbyterian

Guidelines: 

• Field Underwriting Guidelines (Group)
• Individual Underwriting Guidelines - Presbyterian's Individual Plan Field Underwriting Guidelines are currently undergoing revisions. Questions? Please contact your Sales Representative at (505) 923-8200, option 4.

Forms:

• HIPAA - Release of General Health Records Form
• My Care Unique Service Reimbursement Form
• PresMetro Unique Service Reimbursement Form
• Member Termination/Change Form (for groups only)

Questions and Answers:

• Commonly asked questions about non-par providers (R&C, DDs etc)
• 4-Tier Prescription Drug commonly asked questions

Presbyterian Group Benefit Information:

Side-by-Sides

• Value Care Plans (Group size 2-50 HMO)
• Smart Care Plans (Group size 2-50 HMO)
• Preferred Care Plans (Group size 2-50 PPO)
• Advantage Care Plans (Group size 2-50 HDHP, qualified HSA plans)
• Choice Care Plans (Group size 4-50 POS) 
• My Care Plans (Group size 4+ HMO)
• Custom Care Plans (Group size 51+ HMO)
• Smart Care Plans (Group size 51+ HMO)
• Preferred Care Plans (Group size 51+ PPO)
• Advantage Care Plans (Group size 51+ HDHP, qualified HSA plans)
• Flex Care Plans (Group size 51+ POS)

Benefit Summaries by Plan Design

Riders

• Prescription Riders HMO (Group size 51+)
• Prescription Riders PPO (Group size 51+)
• Benefit Summaries by Prescription Rider Design
• Benefit Summaries by Substance Abuse Rider Design (Group size 51+)  
• VSP Vision Riders (Group size 2+)

Forms for Quoting a Group with Presbyterian

• Rate Request Form
• Census Form
• UMAF Medical Assessment Form/English
• UMAF Medical Assessment Form/Spanish 

Forms for Enrolling a Group with Presbyterian

• Enrollment Checklist 
• Employer Group Information Sheet 
• Employee Action Form PIC/PHP (enrollment /change /waiver) 
• Spanish Employee Action Form PIC/PHP (enrollment /change /waiver) 
• PHP Individual Assessment Form 
• PIC Individual Assessment Form
• Exhibit B, Bank Draft Authorization (Required for Groups 2-9) 
• PEO/Leased Employee Verification Form 
• Transition of Care Form

Individual Plans:

• More information about Presbyterian's Individual Plans 
• Apply Online 
• Individual Enrollment Application
• Rates - PresSolo
• Rates-PresMetro
• Rates-Advantage Care
• Rates- Individual Care
• Declination List 
• Benefit Change - Medical Questionnaire
• PresSolo Plan Side-by-Side
• PresMetro Plan Side-by-Side
• Individual Care Plan Side-by-Side
• Advantage Care Plan Side-by-Side
• Individual Member Add Dependent Form
• Individual Member Benefit Change Form
• Individual Member Termination Form
• PresMetro Unique Services Reimbursement Form
• PresSolo Unique Services Reimbursement Form

Summary of all Individual Plans offered

PresSolo Plans

• $500 deductible 70/30 co-insurance standard dental
• $750 deductible 70/30 co-insurance standard dental
• $1000 deductible 70/30 co-insurance standard dental
• $2000 deductible 70/30 co-insurance standard dental
• $5000 deductible 70/30 co-insurance standard dental
• $500 deductible 70/30 co-insurance member option dental
• $750 deductible 70/30 co-insurance member option dental
• $1000 deductible 70/30 co-insurance member option dental
• $2000 deductible 70/30 co-insurance member option dental
• $5000 deductible 70/30 co-insurance member option dental

PresMetro Plans

• $500 deductible 80/20 co-insurance standard dental
• $750 deductible 80/20 co-insurance standard dental
• $1000 deductible 80/20 co-insurance standard dental
• $2000 deductible 80/20 co-insurance standard dental
• $5000 deductible 80/20 co-insurance standard dental
• $500 deductible 80/20 co-insurance member option dental
• $750 deductible 80/20 co-insurance member option dental
• $1000 deductible 80/20 co-insurance member option dental
• $2000 deductible 80/20 co-insurance member option dental
• $5000 deductible 80/20 co-insurance member option dental

Individual Care Plans

• $500 deductible 80/20 co-insurance
• $750 deductible 80/20 co-insurance
• $1000 deductible 80/20 co-insurance
• $1500 deductible 70/30 co-insurance
• $2000 deductible 80/20 co-insurance
• $2500 deductible 70/30 co-insurance

Advantage Care Plans
High Deductible Health Plans, qualified for use with Health Savings Accounts

• $1200 deductible 80/20 with Rx
• $1200 deductible 80/20 without Rx
• $2500 deductible 80/20 with Rx
• $2500 deductible 80/20 without Rx
• $5000 deductible 80/20 with Rx
• $5000 deductible 80/20 without Rx

• Delta Dental (PresMetro & PresSolo) 
• Dental Source (Individual Care & Advantage Care)
• VSP (PresMetro & PresSolo)

K-1 or Individual Conversion Plans

• Individual Action Form (Application)
• K-1 Benefit Summary
• Presbyterian Insurance Company Individual Conversion Benefit Summary
• Presbyterian Health Plan Individual Conversion Benefit Summary

Health Savings Account Information

Individuals that enroll as a Presbyterian Advantage Care Plan member may obtain a Health Savings Account (HSA) through WellsFargo at a reduced administrative cost. Find out more about a WellsFargo HSA account.