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Forms and Documents

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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Forms

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

    This form allows you to submit a dental claim having visited a nonparticipating dentist. All participating network dentists must submit claims forms directly to GHI for processing.

  • Patient and Physician Statement Claim Form - HIP

    Patient and Physician Statement Claim Form for HIP members

  • Pharmacy Benefit Services Prescription Drug Claim Form - EmblemHealth

    This form allows you to submit claims for EmblemHealth prescriptions.

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

    Authorization, Verification and Certification Forms Authorization to Use and Disclose Protected Health Information A written authorization is required for your plan to share a member's protected health information with anyone, except as required or permitted by law.

  • Young Adult Election and Eligibility Form - GHI, EmblemHealth

    Use this form if you are a plan member or the child of a plan member who is now a young adult and wants to be covered under your parent's plan. Members who have an On Exchange plan must contact NYSOH at 1‑855‑355‑5777 to elect coverage under the Young Adult rider.

  • Young Adult Election and Eligibility Form - HIP

    Use this form if you are a plan member or the child of a plan member who is now a young adult and wants to be covered under your parent's plan.

  • Student Verification Form - EmblemHealth, GHI

    If your dependent is a student, use this form to prove enrollment in a higher education school.

  • Student Verification Form for NYS Enrollees Only - GHI

    If your dependent is a student, use this form to prove enrollment in a higher education school.

  • Disability Status Request Form - GHI, EmblemHealth, HIP

    Use this form to maintain coverage for your dependent who has not married, is disabled, and became disabled before reaching the age at which dependent coverage would otherwise end. NYSHIP members must obtain the Statement of Disability form (PS-451) from their health benefits administrator.

  • Medical Records Transfer Request - HIP

    When members are changing their primary care physicians (PCPs) from different medical centers or private physician offices, this form should be used.

  • Coordination of Benefits EmblemHealth - EmblemHealth

    This form assists you in the coordination of benefits received under more than one health insurance program by you or any dependent.

  • Coordination of Benefits HMO - HIP

    This form assists you in the coordination of benefits received under more than one health insurance program by you or any dependent.

  • Coordination of Benefits PPO - GHI

    This form assists you in the coordination of benefits received under more than one health insurance program by you or any dependent.

  • Fitness Facility Member Verification Form - EmblemHealth

    If your benefit plan includes the ExerciseRewardsTM Program, use this form to verify you are a member at a fitness facility.

  • Get Paid Back for Your Fitness Facility Dues - EmblemHealth

    With the ExerciseRewardsTM program, you can enjoy the benefits of exercise and get paid back for your dues.

  • Payout Request Form Log - EmblemHealth

    If your benefit plan includes the ExerciseRewardsTM Program, use this form to get back up to $200 of your membership dues.


QuickStart Guides

Get easy online access to your Quick Start Guide to help you get the most out of your health plan.

  • EmblemHealth 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

  • EmblemHealth Essential Plan

  • EmblemHealth InBalance EPO

  • EmblemHealth InBalance PPO

  • EmblemHealth PPO

  • GHI HMO

  • Health Essentials Plus EPO

  • HIP HMO Preferred Plan

  • 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

List of Covered Drugs

  • 2019 Essential Plan Formulary

    The list of drugs we cover under the Essential Plan for New York State of Health members. It is up to date as of September 1, 2019.

  • 2019 Qualified Health Plan Formulary

    The list of drugs we cover under the Qualified Health Plan for New York State of Health members. It is up to date as of September 1, 2019.

  • 2019 Large Group Formulary

    This is a list of the most commonly prescribed preferred drugs for members with the Large Group Formulary (over 50 eligible).

  • 2019 Small Group Formulary

    This is a list of the most commonly prescribed preferred drugs for members with the Small Group Formulary (Effective July 1, 2019).

  • 2019 Child Health Plus Formulary

    This is a list of the most commonly prescribed preferred drugs for members with the Child Health Plus Formulary (Effective July 1, 2019).


Member Handbooks

Your member handbook tells you how your plan coverage works to get the medical care you need and avoid out-of-pocket costs.

  • Enhanced Care (Medicaid)

  • Enhanced Care Plus (HARP)