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 and Documents
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Forms
Find all available forms including authorization forms, claim forms and more.
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Health Insurance Claim Form - EmblemHealth, HIP, GHI
This form is used when seeking reimbursement for non-participating providers.
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Patient and Physician Statement Claim Form - HIP
Patient and Physician Statement Claim Form for HIP members
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Pharmacy Benefit Services Prescription Drug Claim Form - EmblemHealth
This form allows you to submit claims for EmblemHealth prescriptions.
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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.
Quick Start Guides
Get easy online access to your Quick Start Guide to help you get the most out of your health plan.
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EmblemHealth Consumer Direct EPO
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EmblemHealth Consumer Direct PPO
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EmblemHealth Child Health Plus
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EmblemHealth Enhanced Care Medicaid
Individual and Family Plan Documents
Access easy-to-read summaries of the most important things to know about your plan.
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EmblemHealth Silver Value Benefit Summary
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EmblemHealth Silver Value Summary of Benefits and Coverage
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EmblemHealth Silver Value Subscriber Contract
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EmblemHealth Gold Value Benefit Summary
Group Plan Documents
Access easy-to-read summaries of the most important things to know about your plan.
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EmblemHealth Platinum Premier Benefit Summary
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Platinum Premier Summary of Benefits and Coverage
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Platinum Premier Subscriber Certificate
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Platinum Premier Dental
2019 Direct from EmblemHealth (Non-standard)
Formularies
List of Covered Drugs
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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.
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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.
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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).
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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).
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.
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Enhanced Care (Medicaid)
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Enhanced Care Plus (HARP)
