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Bronze Plan 1 Forms & Documents

Frequently Accessed Documents

.2018 Bronze 1 - 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. See the Subscriber Agreement for details.

.2018 Subscriber Agreement.

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.

.2019 Bronze 1 - 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. See the Subscriber Agreement for details.

.2018 Application for Individual & Family Plan.

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

.2019 Rate Sheet for All Areas.

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.

.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.

Benefits & Coverage

.2018 Bronze 1 - 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. See the Subscriber Agreement for details.

.2018 Rate Sheet for Albuquerque and Santa Fe Area.

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.

.2018 Rate Sheet for All Areas.

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.

.2018 Rate Sheet for Counties other than Bernalillo, Torrance, Sandoval, Valencia, Santa Fe, Las Cruces, and Farmington.

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.

.2018 Rate Sheet for Las Cruces and Farmington Counties.

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.

.2018 Subscriber Agreement.

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.

.2019 Bronze 1 - 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. See the Subscriber Agreement for details.

.2019 Subscriber Agreement.

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.

.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.

Enrollment & Renewal

.2018 Application for Individual & Family Plan.

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

.2018 Individual & Family Plan Dental Benefit Summary & Authorization Form.

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

.2018 Individual & Family Plan Vision Benefit Summary & Authorization Form.

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

.2019 Application for Individual & Family Plan.

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

.2019 Individual & Family Plan Dental Benefit Summary & Authorization Form.

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

.2019 Individual & Family Plan Vision Benefit Summary & Authorization Form.

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

.2019 Rate Sheet for Albuquerque and Santa Fe Area.

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.

.2019 Rate Sheet for All Areas.

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.

.2019 Rate Sheet for All Other New Mexico Areas.

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.

.2019 Rate Sheet for Las Cruces and Farmington Counties.

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.

.Change Authorization Agreement for Prepayments.

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.

.Change Authorization Agreement for Prepayments.

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 Transition Care Services.

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

.Qualifying Event or Move Dependent Form.

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

.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 - 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 Changes.

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

.Drug Formulary Changes.

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

.Drugs Requiring Prior Authorization.

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

.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.

.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.

.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.

.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

.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 Make a Medical or Pharmacy Reimbursement Claim.

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

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.

.Non-emergency Care Options.

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