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Catastrophic Plan Forms & Documents

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Frequently Accessed Documents

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. See the Subscriber Agreement for details.

This legal document explains benefits and features for: PLATINUM; GOLD 1, 2; SILVER 2, 3, 4; BRONZE 1, 3; and Catastrophic. This agreement and the Summary of Benefits and Coverage describe how to use services, covered benefits, out-of-pocket costs etc.

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. See the Subscriber Agreement for details.

Form to enroll in an Individual & Family Plan by fax or mail.

Rates for all New Mexico Counties. Plans listed are Gold, Silver, Bronze, and Catastrophic. Rates are based on age and plan chosen. Note: Premium may change in member birthday month.

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.

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.

List of the prescription drugs 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

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. See the Subscriber Agreement for details.

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. See the Subscriber Agreement for details.

Rates for Bernalillo, Torrance, Sandoval, Valencia, Santa Fe Counties and zip code 87015 (Edgewood). Plans listed are Platinum, Gold, Silver, Bronze, and Catastrophic. Rates are based on age and plan chosen. Note: Premium may change in member birthday month.

Rates for all New Mexico Counties. Plans listed are Gold, Silver, Bronze, and Catastrophic. Rates are based on age and plan chosen. Note: Premium may change in member birthday month.

Rates for Counties other than Bernalillo, Torrance, Sandoval, Valencia, Santa Fe, Las Cruces, and Farmington. Plans listed are Gold, Silver, Bronze, and Catastrophic. Rates are based on age and plan chosen. Note: Premium may change in member birthday month.

Rates for Las Cruces & Farmington Counties. Plans listed are Platinum, Gold, Silver, Bronze, and Catastrophic. Rates are based on age and plan chosen. Note: Premium may change in member birthday month.

This legal document explains benefits and features for: PLATINUM; GOLD 1, 2; SILVER 2, 3, 4; BRONZE 1, 3; and Catastrophic. This agreement and the Summary of Benefits and Coverage describe how to use services, covered benefits, out-of-pocket costs etc.

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features. See the Subscriber Agreement for details.

This legal document explains benefits and features for: PLATINUM; GOLD 1, 2; SILVER 2, 3, 4; BRONZE 1, 3; and Catastrophic. This agreement and the Summary of Benefits and Coverage describe how to use services, covered benefits, out-of-pocket costs etc.

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

Enrollment & Renewal

Form to enroll in an Individual & Family Plan by fax or mail.

Summary and Authorization Form for Dental Plans available to Individual and Family Plan members.

Summary and Authorization form for Vision Plans available to Individual and Family Plan members.

Form to enroll in an Individual & Family Plan by fax or mail.

Summary and Authorization Form for Dental Plans available to Individual and Family Plan members.

Summary and Authorization form for Vision Plans available to Individual and Family Plan members.

Rates for Bernalillo, Torrance, Sandoval, Valencia, Santa Fe Counties and zip code 87015 (Edgewood). Plans listed are Platinum, Gold, Silver, Bronze, and Catastrophic. Rates are based on age and plan chosen. Note: Premium may change in member birthday month.

Rates for all New Mexico Counties. Plans listed are Gold, Silver, Bronze, and Catastrophic. Rates are based on age and plan chosen. Note: Premium may change in member birthday month.

Rates for Counties other than Bernalillo, Torrance, Sandoval, Valencia, Santa Fe, Las Cruces, and Farmington. Plans listed are Gold, Silver, Bronze, and Catastrophic. Rates are based on age and plan chosen. Note: Premium may change in member birthday month.

Rates for Las Cruces & Farmington Counties. Plans listed are Platinum, Gold, Silver, Bronze, and Catastrophic. Rates are based on age and plan chosen. Note: Premium may change in member birthday month.

Use this form to change the method of subsequent premium payments by completing this form or contacting Presbyterian Customer Service Center by phone at (505) 923-5678 or toll-free at 1-800-356-2219, Monday through Friday from 7:00 a.m. to 6:00 p.m. TTY 711.

Use this form to change the method of subsequent premium payments by completing this form or contacting Presbyterian Customer Service Center by phone at (505) 923-5678 or toll-free at 1-800-356-2219, Monday through Friday from 7:00 a.m. to 6:00 p.m. TTY 711.

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

Use this form to add or move dependents to or from your existing coverage.

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

Prescription Drugs

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

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.

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.

Summary of the changes to the Presbyterian Individual and Family Metal Plan/Employer Group Metal Plan Formularies.

Summary of the changes to the Presbyterian Individual and Family Metal Plan/Employer Group Metal Plan Formularies.

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

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

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

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

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

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.

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

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

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

Online form to submit a complaint or an appeal.

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

Health & Wellness Information

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.

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