Formularios y documentos

Find benefit summaries, formularies (list of covered drugs), and all necessary forms to get the most out of your EmblemHealth coverage.

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Formularios

Find all available forms including authorization forms, claim forms and more.

  • Health Insurance Claim Form - EmblemHealth, HIP, GHI

    This form is used when seeking reimbursement for non-participating providers.

  • Dental Claim Form - GHI

    Este formulario le permite presentar una reclamación dental habiendo visitado a un dentista no participante. Todos los dentistas participantes de la red deben presentar los formularios de reclamaciones directamente a GHI para ser procesados.

  • Patient and Physician Statement Claim Form - HIP

    Formulario de reclamación de declaración de paciente y médico para miembros de HIP

  • Pharmacy Benefit Services Prescription Drug Claim Form - EmblemHealth

    Este formulario le permite enviar reclamaciones para recetas de EmblemHealth.

  • Authorization to Use and Disclose Protected Health Information - EmblemHealth, GHI, HIP

    Formularios de autorización, verificación y certificación para usar y divulgar información de salud protegida. Se requiere una autorización por escrito para que su plan comparta la información de salud protegida de un miembro con otra persona, excepto que lo exija o permita la ley.

  • Young Adult Election and Eligibility Form - GHI, EmblemHealth

    Use este formulario si es miembro de un plan o hijo de un miembro de un plan que es actualmente adulto joven y quiere recibir cobertura del plan de su padre. Los miembros que tienen un plan On Exchange deben contactarse con NYSOH al 1‑855‑355‑5777 para elegir la cobertura con cargo adicional por adulto joven.

  • Young Adult Election and Eligibility Form - HIP

    Use este formulario si es miembro de un plan o hijo de un miembro de un plan que es actualmente adulto joven y quiere recibir cobertura del plan de su padre.

  • Student Verification Form - EmblemHealth, GHI

    Si su dependiente es estudiante, use este formulario para demostrar que está matriculado en una escuela de educación superior.

  • Student Verification Form for NYS Enrollees Only - GHI

    Si su dependiente es estudiante, use este formulario para demostrar que está matriculado en una escuela de educación superior.

  • Disability Status Request Form - GHI, EmblemHealth, HIP

    Use este formulario para conservar la cobertura de su dependiente discapacitado, que no ha contraído matrimonio y que contrajo la discapacidad antes de alcanzar la edad a la cual de lo contrario finalizaría la cobertura del dependiente. Los miembros de NYSHIP deberán obtener el formulario de declaración de discapacidad (PS-451) de su administrador de beneficios de salud.

  • Medical Records Transfer Request - HIP

    Se debe usar este formulario cuando los miembros cambian médicos de atención primaria (PCP) de diferentes centros médicos u oficinas privadas de médicos.

  • Coordination of Benefits EmblemHealth - EmblemHealth

    Este formulario lo ayuda en la coordinación de beneficios recibidos bajo más de un programa de seguro médico por usted o cualquier dependiente.

  • Coordination of Benefits HMO - HIP

    Este formulario lo ayuda en la coordinación de beneficios recibidos bajo más de un programa de seguro médico por usted o cualquier dependiente.

  • Coordination of Benefits PPO - GHI

    Este formulario lo ayuda en la coordinación de beneficios recibidos bajo más de un programa de seguro médico por usted o cualquier dependiente.

  • Fitness Facility Member Verification Form - EmblemHealth

    Si su plan de beneficios incluye el programa ExerciseRewardsTM, utilice este formulario para verificar que usted es miembro de un gimnasio.

  • Get Paid Back for Your Fitness Facility Dues - EmblemHealth

    Con el programa ExerciseRewardsTM, puede disfrutar de los beneficios de hacer ejercicio y recibir el reembolso de sus cuotas.

  • Payout Request Form Log - EmblemHealth

    Si su plan de beneficios incluye el programa ExerciseRewardsTM, utilice este formulario para recibir un reembolso de hasta $200 de su membresía.


Guías de inicio rápido

Obtenga fácil acceso en línea a su Guía de inicio rápido para aprovechar al máximo su plan de salud.

  • Consumer Direct EPO

  • EmblemHealth Child Health Plus

  • EmblemHealth Enhanced Care Medicaid

  • EmblemHealth Enhanced Care Plus HARP

  • EmblemHealth EPO

  • EmblemHealth EPO Value

  • EmblemHealth HMO Plus

  • EmblemHealth HMO Preferred Plus

  • EmblemHealth HMO Select Care Individual

  • EmblemHealth Prime Individual

  • EmblemHealth Prime SG w Acupuncture

  • EmblemHealth Prime SG without Acupuncture

  • Plan EmblemHealth Essential

  • EmblemHealth InBalance EPO

  • EmblemHealth InBalance PPO

  • EmblemHealth PPO

  • GHI HMO

  • Health Essentials Plus EPO

  • Plan HIP HMO Preferred

  • HIP PRIME HMO

  • HIP PRIME POS

  • HIP SELECT PPO

  • HIPaccess I

  • HIPaccess II


Individual and Family Plan Documents

Access easy-to-read summaries of the most important things to know about your plan.


Group Plan Documents

Access easy-to-read summaries of the most important things to know about your plan.

  • EmblemHealth Platinum Premier Benefit Summary

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Platinum Premier Summary of Benefits and Coverage

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Platinum Premier Subscriber Certificate

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Platinum Premier Dental

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Platinum Choice Benefit Summary

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Platinum Choice Summary of Benefits and Coverage

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Platinum Choice Subscriber Certificate

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Platinum Choice Dental

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Premier Benefit Summary

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Premier Summary of Benefits and Coverage

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Premier Subscriber Certificate

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Premier Dental

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Premier 1 Benefit Summary

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Premier 1 Summary of Benefits and Coverage

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Premier 1 Subscriber Certificate

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Premier 1 Dental

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Plus Benefit Summary

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Plus Summary of Benefits and Coverage

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Plus Subscriber Certificate

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Plus Dental

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Plus 1 Benefit Summary

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Plus 1 Summary of Benefits and Coverage

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Plus 1 Subscriber Certificate

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Plus 1 Dental

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Choice Benefit Summary

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Choice Summary of Benefits and Coverage

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Choice Subscriber Certificate

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Choice Dental

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Value Benefit Summary

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Value Summary of Benefits and Coverage

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Value Subscriber Certificate

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Gold Value Dental

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Premier Benefit Summary

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Premier Summary of Benefits and Coverage

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Premier Subscriber Certificate

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Premier Dental

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Premier 1 Benefit Summary

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Premier 1 Summary of Benefits and Coverage

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Premier 1 Subscriber Certificate

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Premier 1 Dental

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Plus Benefit Summary

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Plus Summary of Benefits and Coverage

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Plus Subscriber Certificate

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Plus Dental

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Plus 1 Benefit Summary

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Plus 1 Summary of Benefits and Coverage

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Plus 1 Subscriber Certificate

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Plus 1 Dental

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Choice Benefit Summary

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Choice Summary of Benefits and Coverage

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Choice Subscriber Certificate

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Choice Dental

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Value Benefit Summary

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Value Summary of Benefits and Coverage

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Silver Value Subscriber Certificate

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Bronze Value Dental

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Bronze Value Benefit Summary

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Bronze Value Summary of Benefits and Coverage

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Bronze Value Subscriber Certificate

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Bronze Value Dental

    2019 Direct from EmblemHealth (Non-standard)

  • EmblemHealth Bronze Plus HSA Benefit Summary

    2019 Direct from EmblemHealth (Standard)

  • EmblemHealth Bronze Plus HSA Summary of Benefits and Coverage

    2019 Direct from EmblemHealth (Standard)

  • EmblemHealth Bronze Plus HSA Subscriber Certificate

    2019 Direct from EmblemHealth (Standard)

  • EmblemHealth Bronze Plus HSA Dental

    2019 Direct from EmblemHealth (Standard)

  • EmblemHealth Gold Open Access (with adult dental and vision) EmblemHealth Benefit Summary

    2018 Direct from EmblemHealth (Nonstandard)

  • EmblemHealth Gold Open Access (with adult dental and vision) Summary of Benefits and Coverage

    2018 Direct from EmblemHealth (Nonstandard)

  • EmblemHealth Gold Open Access (with adult dental and vision) Dental Benefits Summaries

    2018 Direct from EmblemHealth (Nonstandard)

  • EmblemHealth Gold Open Access (with adult dental and vision) Subscriber Certificate

    2018 Direct from EmblemHealth (Nonstandard)

  • EmblemHealth Gold Open Access (with adult dental and vision) Plan Formulary (list of covered drugs)

    2018 Direct from EmblemHealth (Nonstandard)

  • EmblemHealth Silver Value (with adult dental and vision) EmblemHealth Benefit Summary

    2018 Direct from EmblemHealth (Nonstandard)

  • EmblemHealth Silver Value (with adult dental and vision) Summary of Benefits and Coverage

    2018 Direct from EmblemHealth (Nonstandard)

  • EmblemHealth Silver Value (with adult dental and vision) Dental Benefits Summaries

    2018 Direct from EmblemHealth (Nonstandard)

  • EmblemHealth Silver Value (with adult dental and vision) Subscriber Certificate

    2018 Direct from EmblemHealth (Nonstandard)

  • EmblemHealth Silver Value (with adult dental and vision) Plan Formulary (list of covered drugs)

    2018 Direct from EmblemHealth (Nonstandard)

  • EmblemHealth Bronze Value (with adult dental and vision) EmblemHealth Benefit Summary

    2018 Direct from EmblemHealth (Nonstandard)

  • EmblemHealth Bronze Value (with adult dental and vision) Summary of Benefits and Coverage

    2018 Direct from EmblemHealth (Nonstandard)

  • EmblemHealth Bronze Value (with adult dental and vision) Subscriber Certificate

    2018 Direct from EmblemHealth (Nonstandard)

  • EmblemHealth Bronze Value (with adult dental and vision) Plan Formulary (list of covered drugs)

    2018 Direct from EmblemHealth (Nonstandard)

  • EmblemHealth HMO 40/60 (Gold) EmblemHealth Benefit Summary

    2018 Direct from EmblemHealth (Nonstandard)

  • EmblemHealth HMO 40/60 (Gold) Summary of Benefits and Coverage

    2018 Direct from EmblemHealth (Nonstandard)

  • EmblemHealth HMO 40/60 (Gold) Subscriber Certificate

    2018 Direct from EmblemHealth (Nonstandard)

  • EmblemHealth HMO 40/60 (Gold) Plan Formulary (list of covered drugs)

    2018 Direct from EmblemHealth (Nonstandard)

  • EmblemHealth HMO 15/35 (Platinum) Benefit Summary

    2018 Direct from EmblemHealth (Standard)

  • EmblemHealth HMO 15/35 (Platinum) Summary of Benefits and Coverage

    2018 Direct from EmblemHealth (Standard)

  • EmblemHealth HMO 15/35 (Platinum) Subscriber Certificate

    2018 Direct from EmblemHealth (Standard)

  • EmblemHealth HMO 15/35 (Platinum) Plan Formulary (list of covered drugs)

    2018 Direct from EmblemHealth (Standard)

  • EmblemHealth Bronze HSA Benefit Summary

    2018 Direct from EmblemHealth (Standard)

  • EmblemHealth Bronze HSA Summary of Benefits and Coverage

    2018 Direct from EmblemHealth (Standard)

  • EmblemHealth Bronze HSA Subscriber Certificate

    2018 Direct from EmblemHealth (Standard)

  • EmblemHealth Bronze HSA Plan Formulary (list of covered drugs)

    2018 Direct from EmblemHealth (Standard)


Formularies

Lista de medicamentos cubiertos

  • Farmacopea del plan Essential 2019

    Es la lista de medicamentos que cubrimos con el plan Essential para los miembros del Mercado de la Salud del Estado de Nueva York. It is up to date as of 1 de septiembre de 2019.

  • Farmacopea del plan Qualified Health 2019

    Es la lista de medicamentos que cubrimos con el plan Qualified Health para los miembros del Mercado de la Salud del Estado de Nueva York. It is up to date as of 1 de septiembre de 2019.

  • Farmacopea para grupos grandes 2019

    Es una lista de los medicamentos recetados preferidos más comunes para los miembros con la farmacopea para grupos grandes (más de 50 elegibles).

  • Farmacopea para grupos pequeños 2019

    Es una lista de los medicamentos recetados preferidos más comunes para los miembros con la farmacopea para pequeños grupos (vigente a partir del 01 de julio de 2019).

  • Farmacopea de Child Health Plus 2019

    Es una lista de los medicamentos recetados preferidos más comunes para los miembros con la farmacopea para el plan Child Health Plus (vigente a partir del 01 de julio de 2019).


Manuales del miembro

El manual para miembros explica cómo funciona su plan para obtener el cuidado médico que necesita y evitar los costos de desembolso.

  • Enhanced Care (Medicaid)

  • Enhanced Care Plus (HARP)