Coverage That Makes Sense

Presbyterian Health Plan, Inc. wants to help. Below are documents that are frequently requested. If you can't find what you are looking for, please contact us.

General

• Presbyterian Senior Care Table of Commission Rates
• Producer Commissions Authorization/Agreement for Direct Deposit

Forms

• HIPAA - General Release of Information Form: Member/Subscriber
• Medicare Sales Appointment Confirmation Form
• Member Termination/Change Form (for groups only)
• My Care Unique Service Reimbursement Form

Questions and Answers

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

Presbyterian Group Benefit Information

Small Group Application Kit

• 2020 Small Group Application Kit

Benefit Briefs

• PresElect Plans (Group size 2-50 PPO)
• Smart Care Plans (Group size 2-50 HMO)
• Value Care Plans (Group size 2-50 HMO)
• Vantage Care Plans (Group sizes 2-50 and 51+ HDHP, qualified HSA plans)
• Custom Care Plans (Group size 51+ HMO)
• Preferred Care Plans (Group size 51+ PPO)
• Smart Care Plans (Group size 51+ HMO)

Procedural Forms - Quoting a Group with Presbyterian

• Census Form
• Large Group UMAF
• Rate Request Form
• UMAF Medical Assessment Form, English
• UMAF Medical Assessment Form, Spanish

Procedural Forms - Enrolling a Group with Presbyterian

• Employee Action Form, English
• Employee Action Form, Spanish
• Employee Action Form PIC/PHP, Spanish (enrollment /change /waiver)
• Employer Group Information Sheet
• COBRA
• Transition of Care Form

Individual Plans

• Presbyterian's Individual and Family Plans

Questions?

• Call our knowledgeable associates on our Employer/Producer hotline:
• 505-923-5656 or 1-866-246-9877