2024 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
2024 Presbyterian Senior Care (HMO) Plans 1-3 Summary of Benefits2024 Presbyterian UltraFlex (HMO-POS) Plan Summary of Benefits2024 Presbyterian MediCare PPO Plans 1-2 Summary of Benefits2024 Presbyterian Dual Plus (HMO D-SNP) Summary of Benefits 0042024 Presbyterian Dual Plus (HMO D-SNP) Summary of Benefits 005
Evidence of Coverage (EOC)
2024 Presbyterian Senior Care Plan 1 (HMO) Evidence of Coverage (EOC)2024 Presbyterian Senior Care Plan 2 with Rx (HMO) Evidence of Coverage (EOC)2024 Presbyterian Senior Care Plan 3 with Rx (HMO) Evidence of Coverage (EOC)2024 Presbyterian UltraFlex (HMO-POS) Evidence of Coverage (EOC)2024 Presbyterian MediCare PPO Plan 1 Evidence of Coverage (EOC)2024 Presbyterian MediCare PPO Plan 2 with Rx Evidence of Coverage (EOC)2024 Presbyterian Dual Plus (HMO D-SNP) Evidence of Coverage (EOC) 0042024 Presbyterian Dual Plus (HMO D-SNP) Evidence of Coverage (EOC) 005
Annual Notice of Change (ANOC)
2024 Presbyterian Senior Care Plan 1 (HMO) Annual Notice of Change (ANOC)2024 Presbyterian Senior Care Plan 2 with Rx (HMO) Annual Notice of Change (ANOC)2024 Presbyterian Senior Care Plan 3 with Rx (HMO) Annual Notice of Change (ANOC)2024 Presbyterian UltraFlex HMO-POS Annual Notice of Change (ANOC)2024 Presbyterian MediCare PPO Plan 1 Annual Notice of Change (ANOC)2024 Presbyterian MediCare PPO Plan 2 with Rx Annual Notice of Change (ANOC)2024 Presbyterian Dual Plus (HMO D-SNP) Annual Notice of Change (ANOC) 0042024 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
Online Formularies
2024 Online Presbyterian Medicare Advantage FormulariesPrint or Download Formularies
2024 Medicare Formulary (List of Covered Drugs)2024 Presbyterian Dual Plus (HMO D-SNP) Formulary (List of Covered Drugs)2024 Medicare Drug Formulary Changes2024 Medicare Drug Prior Authorization Criteria2024 Medicare Quantity Limits Criteria2024 Medicare Step Therapy Criteria
Forms
Part D Drug Formulary Exceptions
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.