Gold Plan 1 Forms & Documents

FREQUENTLY ACCESSED DOCUMENTS

Online Drug Formulary

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

On exchange plan for Native American or Tribal Member over 300% of FPL. Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features.

On exchange plan for Native American or Tribal Member between 100%-300% of FPL. Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features.

Vision for Children and Vision Basic plans are included with your medical plan. Learn more about these benefits.

Rates for all New Mexico counties. Rates are based on age; premium may change in member birthday month.

This legal document explains the benefits and features of Individual and Family Plans. This agreement and the Summary of Benefits and Coverage describe how to use services, covered benefits, out-of-pocket costs etc.

This legal document explains benefits and features for: GOLD 1, 2, 4, Gold+ with TytoHome; SILVER 5; and BRONZE 1. This agreement and the Summary of Benefits and Coverage describe how to use services, covered benefits, out-of-pocket costs, etc.

On exchange cost share reduction plan for qualifying incomes. Turquoise Plans offer lower out-of-pocket costs and are only available on beWellnm.com. Use this summary to compare costs and coverage between health plans based on price, benefits, network providers, and other features.

On exchange cost share reduction plan for qualifying incomes. Turquoise Plans offer lower out-of-pocket costs and are only available on beWellnm.com. Use this summary to compare costs and coverage between health plans based on price, benefits, network providers, and other features.

Use this summary to compare costs and coverage between health plans based on price, benefits, network providers and other features.

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.

Esta guía aporta información sobre para cuáles tipos de procedimientos se exige la autorización previa [prior authorization, PA]

This guide provides information about what types of procedures need a prior authorization (PA)

ENROLLMENT & RENEWAL

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

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

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.

PRESCRIPTION DRUGS

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

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

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

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

Online Drug Formulary

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.

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.

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.

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.

CLAIMS, APPEALS, RELEASES AND OTHER

Formulario para autorizar a Presbyterian a divulgar su información médica protegida a otro grupo.

Formulario para presentar recibos de reembolso de gastos de bolsillo cubiertos.

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

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

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

Online Form to Submit a Complaint or Appeal

Online form to submit a complaint or an appeal.

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.