Bronze 9450 w/ GYM Forms & Documents
Back to Forms & DocumentsFREQUENTLY ACCESSED DOCUMENTS
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
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 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.
Rates for Bernalillo, Torrance, Sandoval, Santa Fe, and Valencia counties. Rates are based on age; premium may change in member birthday month.
Rates for Counties other than Bernalillo, Torrance, Sandoval, Valencia, Santa Fe, Las Cruces, and Farmington. Rates are based on age and plan chosen. Note: Premium may change in member birthday month.
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.
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.
ENROLLMENT & RENEWAL
Complete guide for enrolling in an Individual & Family Plan.
Form to enroll in an Individual & Family Plan by fax or mail.
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.
Form to register for 3 months of prescriptions to be mailed to you. This service is available for most drugs.
Explanation of Prior Authorization requirements as well as a list of drugs that require prior authorization.
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.
Form for a member, prescriber or a pharmacy to request authorization for a drug listed on the Drugs Requiring Prior Authorization List.
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 health records to another group.
Form to begin an appeal process for dissatisfaction with a service.
This guide provides information about what types of procedures need a prior authorization (PA)
Online form to submit a complaint or an appeal.
Form to submit receipts for reimbursement of covered out-of-pocket expenses.
Esta guía aporta información sobre para cuáles tipos de procedimientos se exige la autorización previa [prior authorization, PA]
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.
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.