2023 Forms, Plan Information, and Policies
Here you will find important forms and plan information related to your Presbyterian Medicare Advantage plan.
Benefits & Coverage
Summary of Benefits
2023 Presbyterian Senior Care (HMO) Plans 1-3 Summary of Benefits2023 Presbyterian UltraFlex (HMO-POS) Plan Summary of Benefits2023 Presbyterian MediCare PPO Plans 1-2 Summary of Benefits2023 Presbyterian Dual Plus (HMO D-SNP) Summary of Benefits 0042023 Presbyterian Dual Plus (HMO D-SNP) Summary of Benefits 005
Evidence of Coverage (EOC)
2023 Presbyterian Senior Care Plan 1 (HMO) Evidence of Coverage (EOC)2023 Presbyterian Senior Care Plan 2 with Rx (HMO) Evidence of Coverage (EOC)2023 Presbyterian Senior Care Plan 3 with Rx (HMO) Evidence of Coverage (EOC)2023 Presbyterian UltraFlex (HMO-POS) Evidence of Coverage (EOC)2023 Presbyterian MediCare PPO Plan 1 Evidence of Coverage (EOC)2023 Presbyterian MediCare PPO Plan 2 with Rx Evidence of Coverage (EOC)2023 Presbyterian Dual Plus (HMO D-SNP) Evidence of Coverage (EOC) 0042023 Presbyterian Dual Plus (HMO D-SNP) Evidence of Coverage (EOC) 005
Annual Notice of Change (ANOC)
2023 Presbyterian Senior Care Plan 1 (HMO) Annual Notice of Change (ANOC)2023 Presbyterian Senior Care Plan 2 with Rx (HMO) Annual Notice of Change (ANOC)2023 Presbyterian Senior Care Plan 3 with Rx (HMO) Annual Notice of Change (ANOC)2023 Presbyterian MediCare PPO Plan 1 Annual Notice of Change (ANOC)2023 Presbyterian MediCare PPO Plan 2 with Rx Annual Notice of Change (ANOC)2023 Presbyterian Dual Plus (HMO D-SNP) Annual Notice of Change (ANOC) 0042023 Presbyterian Dual Plus (HMO D-SNP) Annual Notice of Change (ANOC) 005
Provider Directories
Presbyterian Senior Care (HMO) Provider DirectoryPresbyterian UltraFlex (HMO-POS) Provider DirectoryPresbyterian MediCare PPO Provider DirectoryPresbyterian Dual Plus (HMO D-SNP) Provider Directory
Star Ratings
Presbyterian Senior Care (HMO) Star RatingPresbyterian MediCare PPO Star RatingPresbyterian Dual Plus (HMO D-SNP) Star Rating
Additional Resources
Prescription Drugs
Formularies (Drug Lists) and Plan Information
2023 Medicare Formulary (List of Covered Drugs) - Updated 9/1/20232023 Presbyterian Dual Plus (HMO D-SNP) Formulary (List of Covered Drugs) - Updated 9/1/20232023 Medicare Drug Formulary Changes - Updated 9/1/20232023 Medicare Drug Prior Authorization Criteria - Updated 9/1/20232023 Medicare Quantity Limits Criteria - Updated 9/1/20232023 Medicare Step Therapy Criteria - Updated 9/1/2023
2023 Online Presbyterian Medicare Advantage Formularies
Part D Drug Formulary Exceptions
Forms
Form for OptumRx Mail Order PrescriptionsForm to Make a Medical or Pharmacy Reimbursement ClaimForm for Medicare Drug Coverage Determination RequestForm for Presbyterian Dual Plus (HMO D-SNP) Drug Coverage Determination Request
Online Member Appeals Request Form
Extra Help for Prescription Drugs
Enrollment
Claims, Appeals, Releases and Other
Mid Year Changes
If Medicare changes your benefits during the year, we'll post notices here.