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Platinum Plan 1 Forms & Documents

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Benefits & Coverage

.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

.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.

.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.