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Health Plan Forms & Documents

Use the filters below to find important forms and documents related to your Presbyterian health insurance plan.

Frequently Accessed Documents

.Drug Formulary - by Drug Class.

List of the prescription drugs - by drug class - that are covered by your plan. Explains if Prior Authorizations are needed, what the Quantity Limits are, and other conditions to have the drug.

Benefits & Coverage

.2014 - 2015 Non-Medicare Participant Benefit Booklet.

Summary of the UNM plan and the associated out-of-pocket expenses for services and prescriptions

.2014 - 2015 Non-Medicare PPO Summary of Benefits and Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.2014 Benefits Summary.

Summary of the UFCW plan and the associated out-of-pocket expenses for services and prescriptions

.2015 Albuquerque Public Schools Summary of Benefits and Coverage (SBC), Family.

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.2015 Albuquerque Public Schools Summary of Benefits and Coverage (SBC), Subscriber.

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.2015 Benefits Handbook.

This brochure is the official statement of benefits that are available to Federal Employee. It explains how the plan works, your benefits and out-of-pocket costs.

.2015 Group Metal HDHP (HMO) Group Subscriber Agreement (GSA).

This legal document, along with the Summary of Benefits and Coverage, describes the Benefits and plan features you are eligible to receive.

.2015 Group Metal HDHP (PPO) Group Subscriber Agreement (GSA).

This legal document, along with the Summary of Benefits and Coverage, describes the Benefits and plan features you are eligible to receive.

.2015 Group Metal HMO Group Subscriber Agreement (GSA).

This legal document, along with the Summary of Benefits and Coverage, describes the Benefits and plan features you are eligible to receive.

.2015 Intel Summary of Benefits and Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.2015 Isleta HDHP Summary of Benefits and Coverage (SBC), Family.

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.2015 Isleta HDHP Summary of Benefits and Coverage (SBC), Subscriber.

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.2015 Isleta HMO Summary of Benefits and Coverage (SBC), Family.

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.2015 Isleta HMO Summary of Benefits and Coverage (SBC), Subscriber.

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.2015 Isleta PPO Summary of Benefits and Coverage (SBC), Family.

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.2015 Isleta PPO Summary of Benefits and Coverage (SBC), Subscriber.

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.2015 Summary of Benefits & Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.Albuquerque Public Schools Benefit Guide.

Brief summary of benefits, limits and/or exclusions.

.Benefits Summary (Current).

Summary of the Intel HMO plan and the associated out-of-pocket expenses for services and prescriptions

.CABQ Medical Plan Decision Tool.

Use this Medical Plan Decision Tool to help determine which plan is right for you.

.Covered Preventive Care Services with No Co-Pay.

List of preventive care services available at no cost when you are seen by an in-network provider.

.EPO Family Summary of Benefits and Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.EPO Summary of Benefits and Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.EPO Summary Plan Description.

Document describing the details of your plan.

.Federal Employees Benefit Guide.

Brief summary of benefits, limits and/or exclusions.

.Form for Coordination of Benefits.

Form to provide information about your other health plan coverage.

.HDHP Summary of Benefits and Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.HDHP Summary Plan Description.

Description of your group Plan medical benefits and limitations.

.Intel Benefit Guide.

Brief summary of benefits, limits and/or exclusions.

.Isleta Benefit Guide.

Brief summary of benefits, limits and/or exclusions.

.Large Group HDHP Group Subscriber Agreement (GSA).

This legal document, along with the Summary of Benefits and Coverage, describes the Benefits and plan features you are eligible to receive.

.Large Group HMO Group Subscriber Agreement (GSA).

This legal document, along with the Summary of Benefits and Coverage, describes the Benefits and plan features you are eligible to receive.

.Large Group PPO Group Subscriber Agreement (GSA).

This legal document, along with the Summary of Benefits and Coverage, describes the Benefits and plan features you are eligible to receive.

.Member Benefit Booklet.

Summary of the Copayment amounts for specific services your plan. For detailed descriptions, see Your Group Subscriber Agreement

.My Care Active and Family Group Subscriber Agreement.

Document describing the details of your plan

.My Care Active and Family with Gym Group Subscriber Agreement.

Document describing the details of your plan

.My Care Active Plan Benefit Guide.

Summary of benefits about your plan

.My Care Active Plan Summary of Benefits & Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.My Care Active Plan with Dependents and Gym Summary of Benefits & Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.My Care Active Plan with Dependents Summary of Benefits & Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.My Care Active Plan with Gym Summary of Benefits & Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.My Care Family Plan Benefit Guide.

Summary of benefits about your plan

.My Care Family Plan Summary of Benefits & Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.My Care Family Plan with Dependents and Gym Summary of Benefits & Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.My Care Family Plan with Dependents Summary of Benefits & Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.My Care Family Plan with Gym Summary of Benefits & Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.My Care Independent Group Subscriber Agreement.

Document describing the details of your plan

.My Care Independent Plan Benefit Guide.

Summary of benefits about your plan

.My Care Independent Plan Summary of Benefits & Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.My Care Independent Plan with Dependents and Gym Summary of Benefits & Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.My Care Independent Plan with Dependents Summary of Benefits & Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.My Care Independent Plan with Gym Summary of Benefits & Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.My Care Independent with Gym Group Subscriber Agreement.

Document describing the details of your plan

.New Mexico Retiree Health Care Member Benefit Booklet.

Summary of the New Mexico Retiree Health Cares plan and the associated out-of-pocket expenses for services and prescriptions

.New Mexico Retiree Health Care Premium Benefit Guide.

Brief summary of benefits, limits and/or exclusions.

.New Mexico Retiree Health Care Premium Plus Benefit Guide.

Brief summary of benefits, limits and/or exclusions.

.Plan B Summary of Benefits and Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.Plan B Summary Plan Description.

Description of your group Plan medical benefits and limitations.

.PPO Family Summary of Benefits and Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.PPO Summary of Benefits and Coverage (SBC).

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. The Summary of Benefits and Coverage (SBC) is helpful to understand new coverage, renewals or change in coverage.

.PPO Summary Plan Description.

Document describing the details of your plan.

.Preferred Care PPO Group Subscriber Agreement (GSA).

This legal document, along with the Summary of Benefits and Coverage, describes the Benefits and plan features you are eligible to receive.

.Premier and Premier Plus Member Benefits Summary.

Summary of the NMRHCA Premier and Premier Plus plans and the associated out-of-pocket expenses for services and prescriptions

.Smart Care HMO Group Subscriber Agreement (GSA).

This legal document, along with the Summary of Benefits and Coverage, describes the Benefits and plan features you are eligible to receive.

.State of New Mexico Benefit Guide.

Brief summary of benefits, limits and/or exclusions.

.Contact Information for Benefits Departments.

Phone numbers for the benefit offices of the towns that are part of the City of Albuquerque plan

.Form for Unique Services Reimbursement.

Unique Services Reimbursement Program applies to Independent and Active plans only. Benefits are on a calendar year, have limitiations, and requests must be submitted within one year from the date of service.

.Herramientas en línea para los miembros de Presbyterian Centennial Care.

Folleto enumerando las formas de obtener ayuda con su cuidado de Centennial en línea - www.phs.org / centennialcare o por teléfono 1-888-977-2333

.Online Tools for Presbyterian Centennial Care Members.

Brochure listing the ways to get help with your Centennial Care online - www.phs.org/centennialcare or over the phone 1-888-977-2333

.Understand Your Health Benefits on Foreign Travel.

Participant benefits for urgent and emergency services received outside of the United States

Enrollment & Renewal

.Form to Transition Care Services.

Form to help you transition you or your family's health care to Presbyterian

.Form to Cancel Your Plan.

Form to end plan coverage by cancelling some or all members on a Presbyterian Health Plan

Prescription Drugs

.Contraceptives Covered with No Co-Pay.

Lists contraception available at no co-pay nor deductible, if your plan includes a Women's preventive medication coverage feature.

.Drug Formulary - By Drug Class.

List of the prescription drugs - by drug class - that are covered by your plan. Explains if Prior Authorizations are needed, what the Quantity Limits are, and other conditions to have the drug.

.Drug Formulary - Alphabetical.

List of the prescription drugs - by alphabetical order - that are covered by your plan. Explains if Prior Authorizations are needed, what the Quantity Limits are, and other conditions to have the drug.

.Drug Formulary - Alphabetical.

List of the prescription drugs - by alphabetical order - that are covered by Presbyterian Centennial Care Medicaid. Explains if Prior Authorizations are needed, what the Quantity Limits are, and other conditions to have the drug. (Updated 6/1/14)

.Drug Formulary - by Drug Class.

List of the prescription drugs - by drug class - that are covered by your plan. Explains if Prior Authorizations are needed, what the Quantity Limits are, and other conditions to have the drug.

.Drug Formulary - by Drug Class.

List of the prescription drugs - by drug class - that are covered by your plan. Explains if Prior Authorizations are needed, what the Quantity Limits are, and other conditions to have the drug.

.Drugs Requiring Prior Authorization.

Explanation of Prior Authorization requirements as well as a list of drugs that require prior authorization

.Form for Current Medication List.

Form to identify current medications that may not be included on the Presbyterian Formulary.

.Form for OptumRx Mail Order Prescriptions.

Form to register for 3 months of prescriptions to be mailed to you. This service is available for most drugs.

.Form Requesting Prior Authorization for Drugs.

Form for a member, prescriber or a pharmacy to request authorization for a drug listed on the Drugs Requiring Prior Authorization List.

.Personal Medication List.

Blank list to help you keep track of your medications.

.Pharmacy Locations.

List of all the Pharmacies available on Presbyterian Health Plans. Note that some drugs are required to be obtained through a specialty pharmacy provider.

.Pharmacy Locations.

List of all the Pharmacies available for Presbyterian Centennial Care Medicaid. Note that some drugs are required to be obtained through a specialty pharmacy provider.

.Policy for Medicare Part D Drug Transitions.

Explanation of the Transition Policy for prescribed drugs from other Plan D providers to the Presbyterian Medicare Advantage Plans

.What If My Drug Is Not on the Formulary?.

If the prescribed drug you need is not covered by your plan, call the PCSC for help or ask your doctor for a different drug that is covered

.La lista de medicamentos preferidos en orden alfabetica.

Este formulario de medicamentos está en orden alfabética.Revise el documento para asegurarse de que aún incluya los medicamentos que toma. En general, debe utilizar las farmacias de la red para utilizar su beneficio de medicamentos con receta médica.

.Las farmacias de la red de Presbyterian.

Utilice esta lista para encontrar las farmacias de la red de Presbyterian. Esta lista está sujeta a cambios.

.Lista Personal de Medicamentos.

Lista en blanco para ayudar a mantener un registro de sus medicamentos.

.Specialty Pharmacy & Medical Drugs Coverage.

List of drugs that are Specialty (given by self) and Medical (given by doctor). Some of the drugs on the list must be provided by a Specialty Care Pharmacy. There may also be Prior Authorizations or Medical Exceptions needed.

Claims, Appeals, Releases and Other

.Aviso de no discriminación.

Presbyterian Health Services (Presbyterian) cumple con todas las ley es de derechos civiles federales aplicables y no discrimina sobre la base de la raza, color, naciona lidad, edad, discapacidad o sexo. Presbyterian no excluye a las personas ni las trata de manera diferente en base a la raza, color, nacionalidad, edad, discapacidad o sexo.

.Form to Reimburse (Direct Deposit) Traditional Healer Benefit Expense.

Form to request direct deposit reimbursement for services completed by a Traditional Healer. Receive up to $200 back each year.

.Form to Release General Health Records.

Form to authorize Presbyterian to disclose your healh records to another group.

.Form to Request an Initial Appeal.

Form to begin an appeal process for dissatisfaction with a service.

.Online Form to Submit a Complaint or Appeal.

Online form to submit a complaint or an appeal.

.Form to Acknowledge Traditional Healer Benefit.

Form to indicate you will be receiving services by a Traditional Healer. Use the reimbursement form after the services are received for repayment (up to $200 per year)

.Form to Make a Medical or Pharmacy Reimbursement Claim.

Form to submit receipts for reimbursement of covered out-of-pocket expenses.

.Form to Reimburse Traditional Healer Benefit Expense.

Form to request reimbursement for services completed by a Traditional Healer. Receive up to $200 back each year.

.Transportation, Lodging & Meals FAQs.

Information to request transportation to an appointment, lodging request for member traveling more than 4 hours one way, and other benefits for members. Call the Presbyterian Customer Service Center at 1-800-977-2333 for more information.

Health & Wellness Information

.Create an Advanced Healthcare Directive.

Instructions to help you create a legal document about two important healthcare choices: Who you will speak for you if you become ill and what medical support you may want if you become seriously ill.

.MediCare PPO Health Assessment.

Survey to allow us to better assess your healthcare needs.

.Presbyterian Senior Care (HMO) Health Assessment.

Survey to allow us to better assess your healthcare needs.

.Adult Preventive Healthcare Guidelines.

Suggestions for adults of tests and screenings to have done and how often.

.Asthma Resource Guide - Adults.

List of simple steps for asthma control and phone numbers and websites to help you understand and manage asthma.

.Asthma Resource Guide - Children.

List of simple steps for asthma control and phone numbers and websites to help you understand and manage asthma.

.Comer bien: beba más agua.

Tome agua en vez de bebidas con azúcar.

.Comer bien: coma más proteínas.

Presbyterian sugiere fibra y proteína que se sienta lleno, lo que significa que va a comer menos calorías.

.Comer bien: el control de las porciones.

Presbyterian sugiere consejos para una alimentación más consciente y mejor control de las porciones

.Comer bien: frutas y vegetales.

Presbyterian sugiere estos consejos prácticos para gradualmente llegar a comer una dieta más fundada en las plantas:

.Cómo mantener a los adolescentes saludables mediante consultas de niño sano..

Guía para el cuidado de los adolescentes con un pozo de visita obligada. Haga una cita con el médico de su hijo adolescente

.Diabetes Resource Guide.

Summary of programs and tests recommended to understand diabetes and how to ask for care.

.Eating Right Tip: Drink More Water.

Presbyterian suggests more water for better health.

.Eating Right Tip: Eat More Protein.

Presbyterian suggests fiber and protein make you feel full, which means you?ll eat fewer calories.

.Eating Right Tip: Fruits & Vegetables.

Presbyterian suggests you Try these practical tips to ease into eating a more plant-based diet:

.Eating Right Tip: Portion Control.

Presbyterian suggests tips for more mindful eating and better portion control.

.Es el cuidado intregal de la diabetes?.

Presbyterian recomienda cinco pruebas cada año para ayudar a controlar su diabetes. ¿Tienes una prueba de HbA1c, un examen de colesterol, un examen de la vista de la retina, pruebas de función renal o presión arterial de este año!

.Form to Enroll in Baby Benefits.

Presbyterian Baby Benefits is a free program that offers tools to help you, the Centennial Care member, with the care you need during your pregnancy and after your baby is born.

.Guía del Presbyterian de recursos del asma para los adultos.

Lista de pasos simples para el control del asma y los números de teléfono y sitios web para ayudar a comprender y tratar el asma.

.Guía del Presbyterian de recursos del asma para los niños.

Lista de pasos simples para el control del asma y los números de teléfono y sitios web para ayudar a comprender y tratar el asma.

.Inscríbase en Beneficios de Presbyterian para Bebés.

Beneficios de Presbyterian para Bebés es un programa gratuito que ofrece herramientas para ayudarle con la atención que usted necesita durante el embarazo y después del nacimiento de su bebé.

.Keeping Teens Healthy with Well-Child Visits.

Guidance for caring for teens with a well-visit. Make an appointment with your teen's doctor.

.La importancia de la salud dental en los niños.

Visitas dentales anuales son muy importantes en el buen crecimiento y desarrollo de los dientes de su hijo. Sírvase llamar al Centro de Atención a los Clientes del Presbyterian al 1-888-977-2333 para programar una cita anual.

.Medicare Nombramiento de un Representante.

Autorización para que un representante para tomar decisiones en nombre de usted, el beneficiario de Medicare

.Non-emergency Care Options.

Chart to help you decide the best care in non-emergency situations. Print a copy and keep nearby.

.Opciones de atención que no constituyen una emergencia..

Gráfico para ayudarle a decidir la mejor atención en situaciones que no son de emergencia. Imprima una copia y tener cerca.

.Paso 1 - Certificado de atención prenatal temprana.

Certificado de atención prenatal temprana

.Paso 2 - Atención prenatal regular.

Certificado de Atención prenatal regular

.Pautas sobre atención médica preventiva de adultos..

Las pruebas médicas los adultos deben tener y con qué frecuencia deben tenerlos.

.Pautas sobre atención médica preventiva en embarazos..

Orientación para las mujeres embarazadas. Horarios de visita al médico, qué esperar durante el embarazo, y las pruebas y exámenes sugeridos.

.Pautas sobre atención médica preventiva pediátrica.

Guía para el cuidado de los niños, agrupados por niño hasta la edad de 1; 2-10; 11-20. Explica cuándo tener las vacunas, prueba y consejería de desarrollo

.Pediatric Preventive Healthcare Guidelines.

Guidance for caring for children, grouped by infant to age 1, ages 2-10, and ages 11-20. Explains when to have vaccinations, tests, and development counseling.

.Por qué usted se debe hacer hoy mismo una mamografía.

Folleto que enumera los beneficios de tener una mamografía - rayos X de los senos

.Pregnancy Preventive Healthcare Guidelines.

Guidance for pregnant women. Doctor visit schedules, what to expect during the pregnancy, and suggested tests and screenings.

.Pruebas recomendadas para la detección de diabetes.

Pruebas recomendadas para la detección de diabetes

.Recommended Diabetes Care Screenings.

Presbyterian recommends five tests each year to help manage your diabetes. Have an HbA1c test, a cholesterol screening, a retinal eye exam, kidney function test or blood pressure checked this year!

.Recursos recomendados sobre la diabetes.

Recursos recomendados sobre la diabetes

.Step 1 - Early Prenatal Visit Certificate.

Form to show you had a prenatal office visit within the first 12 weeks of pregnancy.

.Step 2 - Regular Prenatal Visit Certificate.

Form to show you had a regular prenatal care visits throughout your pregnancy

.The Importance of Dental Health in Children.

Annual dental visits are very important in the good growth and development of your child?s teeth. Call the Presbyterian Customer Service Center at 1-800-797-5343 to schedule an annual appointment.

.Tips & Time Tracker for Staying More Active.

Chart to help you keep track of food and activities a week at a time.

.Why You Should Get a Mammogram Today.

Brochure listing the benefits of having a mammogram - an X-ray of your breasts