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Platinum Plan 1 Forms & Documents

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Benefits & Coverage

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

Enrollment & Renewal

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

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.

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 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.