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.
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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.
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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.
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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.
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Student Verification Form - EmblemHealth, GHI
If your dependent is a student, use this form to prove enrollment in a higher education school.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Dental Claim form
Use this form to submit dental claims to EmblemHealth
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
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EmblemHealth Enhanced Care Plus HARP
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EmblemHealth EPO
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EmblemHealth EPO Value
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EmblemHealth EPO Value HDHP
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EmblemHealth HMO Plus
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EmblemHealth HMO Preferred Plus
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EmblemHealth HMO Select Care Individual
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EmblemHealth Prime Individual
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EmblemHealth Prime SG w Acupuncture
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EmblemHealth Prime SG without Acupuncture
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EmblemHealth Essential Plan
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EmblemHealth InBalance EPO
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EmblemHealth InBalance PPO
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EmblemHealth PPO
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GHI HMO
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Health Essentials Plus EPO
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HIP HMO Preferred Plan
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HIP PRIME HMO
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HIP PRIME POS
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HIP SELECT PPO
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HIPaccess I
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HIPaccess II
2021 Individual and Family Plan Documents
Access easy-to-read summaries of the most important things to know about your plan.
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2021 Basic (Catastrophic) Benefit Summary
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2021 Basic (Catastrophic) Summary of Benefits and Coverage
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2021 Basic (Catastrophic) Subscriber Contract
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2021 Bronze Benefit Summary
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2021 Bronze Summary of Benefits and Coverage
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2021 Bronze Subscriber Contract
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2021 Essential Plan 1 Benefit Summary
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2021 Essential Plan 1 Summary of Benefits and Coverage
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2021 Essential Plan 1 Plus Benefit Summary
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2021 Essential Plan 1 Plus Summary of Benefits and Coverage
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2021 Essential Plan 1 and 2 Native American Benefit Summary
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2021 Essential Plan 1 and 2 Plus Native American Benefit Summary
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2021 Essential Plan 2 Benefit Summary
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2021 Essential Plan 2 Summary of Benefits and Coverage
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2021 Essential Plan 2 Plus Benefit Summary
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2021 Essential Plan 2 Plus Summary of Benefits and Coverage
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2021 Essential Plan 3 Benefit Summary
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2021 Essential Plan 3 Summary of Benefits and Coverage
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2021 Essential Plan 4 Benefit Summary
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2021 Essential Plan 4 Summary of Benefits and Coverage
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2021 Gold Benefit Summary
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2021 Gold Summary of Benefits and Coverage
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2021 Gold Subscriber Contract
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2021 Gold Value Benefit Summary
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2021 Gold Value Summary of Benefits and Coverage
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2021 Gold Value Subscriber Contract
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2021 Platinum Benefit Summary
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2021 Platinum Summary of Benefits and Coverage
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2021 Platinum Subscriber Contract
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2021 Silver Benefit Summary
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2021 Silver Summary of Benefits and Coverage
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2021 Silver Subscriber Contract
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2021 Silver Bold Benefit Summary
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2021 Silver Bold Summary of Benefits and Coverage
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2021 Silver Bold Subscriber Contract
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2021 Bold CSR 1, Bold CSR 2, Bold CSR 3 Benefit Summary
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2021 Bold CSR 1, Bold CSR 2, Bold CSR 3 Summary of Benefits and Coverage
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2021 Bold CSR 1, Bold CSR 2, Bold CSR 3 Subscriber Contract
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2021 Silver CSR 1, CSR 2, CSR 3 Benefit Summary
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2021 Silver CSR 1, CSR 2, CSR 3 Summary of Benefits and Coverage
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2021 Silver CSR 1, CSR 2, CSR 3 Subscriber Contract
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2021 Silver Value Benefit Summary
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2021 Silver Value Summary of Benefits and Coverage
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2021 Silver Value Subscriber Contract
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2021 Silver Value CSR 1, CSR 2, CSR 3 Benefit Summary
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2021 Silver Value CSR 1, CSR 2, CSR 3 Summary of Benefits and Coverage
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2021 Silver Value CSR 1, CSR 2, CSR 3 Subscriber Contract
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2021 Standard Native American/Alaskan Native
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2021 Non-Standard Native American/Alaskan Native
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2021 Silver Bold Non-Standard Native American/Alaskan Native
2021 Group Plan Documents
Access easy-to-read summaries of the most important things to know about your plan.
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2021 Bronze Plus H.S.A.
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Bronze Premier M
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Bronze Premier P
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Bronze Premier S
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Bronze Value M
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Bronze Value P
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Bronze Value S
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Gold EPO Virtual-M
Benefit Summary
Summary of Benefits and Coverage (SBC) -
2021 Gold EPO Virtual-N
Benefit Summary
Summary of Benefits and Coverage (SBC) -
2021 Gold PPO-N
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Gold Premier M
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Gold Premier P
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Gold Premier S
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Gold Value M
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Gold Value P
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Gold Value S
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Healthy NY Gold
Benefit Summary
Summary of Benefits and Coverage (SBC) -
2021 Platinum PPO-N
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Platinum Premier M
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Platinum Premier P
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Platinum Premier S
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Platinum Value M
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Platinum Value P
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Platinum Value S
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Silver Plus H.S.A.
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Silver Premier M
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Silver Premier P
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Silver Premier S
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Silver Value M
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Silver Value P
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract -
2021 Silver Value S
Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract
2019 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
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EmblemHealth Gold Value Summary of Benefits and Coverage
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EmblemHealth Gold Value Subscriber Contract
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EmblemHealth Platinum Benefit Summary
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EmblemHealth Platinum Summary of Benefits and Coverage
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EmblemHealth Platinum Subscriber Contract
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EmblemHealth Gold Benefit Summary
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EmblemHealth Gold Summary of Benefits and Coverage
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EmblemHealth Gold Subscriber Contract
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EmblemHealth Silver Benefit Summary
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EmblemHealth Silver Summary of Benefits and Coverage
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EmblemHealth Silver Subscriber Contract
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EmblemHealth Bronze Benefit Summary
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EmblemHealth Bronze Summary of Benefits and Coverage
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EmblemHealth Bronze Subscriber Contract
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EmblemHealth Basic Benefit Summary
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EmblemHealth Basic Summary of Benefits and Coverage
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EmblemHealth Basic Subscriber Contract
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EmblemHealth Essential Plan 1 Benefit Summary
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EmblemHealth Essential Plan 1 Summary of Benefits and Coverage
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EmblemHealth Essential Plan 1 Subscriber Contract
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EmblemHealth Essential Plan 1 with dental and vision Benefit Summary
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EmblemHealth Essential Plan 1 with dental and vision Summary of Benefits and Coverage
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EmblemHealth Essential Plan 1 with dental and vision Subscriber Contract
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EmblemHealth Essential Plan 2 Benefit Summary
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EmblemHealth Essential Plan 2 Summary of Benefits and Coverage
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EmblemHealth Essential Plan 2 Subscriber Contract
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EmblemHealth Essential Plan 1 and 2 Native American Benefit Summary
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EmblemHealth Essential Plan 1 Plus and 2 Plus Native American Benefit Summary
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EmblemHealth Essential Plan 3 Benefit Summary
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EmblemHealth Essential Plan 3 Summary of Benefits and Coverage
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EmblemHealth Essential Plan 3 Subscriber Contract
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EmblemHealth Essential Plan 4 Benefit Summary
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EmblemHealth Essential Plan 4 Summary of Benefits and Coverage
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EmblemHealth Essential Plan 4 Subscriber Contract
2019 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)
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EmblemHealth Platinum Choice Benefit Summary
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Platinum Choice Summary of Benefits and Coverage
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Platinum Choice Subscriber Certificate
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Platinum Choice Dental
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Premier Benefit Summary
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Premier Summary of Benefits and Coverage
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Premier Subscriber Certificate
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Premier Dental
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Premier 1 Benefit Summary
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Premier 1 Summary of Benefits and Coverage
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Premier 1 Subscriber Certificate
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Premier 1 Dental
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Plus Benefit Summary
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Plus Summary of Benefits and Coverage
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Plus Subscriber Certificate
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Plus Dental
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Plus 1 Benefit Summary
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Plus 1 Summary of Benefits and Coverage
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Plus 1 Subscriber Certificate
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Plus 1 Dental
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Choice Benefit Summary
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Choice Summary of Benefits and Coverage
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Choice Subscriber Certificate
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Choice Dental
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Value Benefit Summary
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Value Summary of Benefits and Coverage
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Value Subscriber Certificate
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Gold Value Dental
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Premier Benefit Summary
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Premier Summary of Benefits and Coverage
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Premier Subscriber Certificate
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Premier Dental
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Premier 1 Benefit Summary
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Premier 1 Summary of Benefits and Coverage
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Premier 1 Subscriber Certificate
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Premier 1 Dental
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Plus Benefit Summary
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Plus Summary of Benefits and Coverage
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Plus Subscriber Certificate
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Plus Dental
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Plus 1 Benefit Summary
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Plus 1 Summary of Benefits and Coverage
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Plus 1 Subscriber Certificate
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Plus 1 Dental
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Choice Benefit Summary
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Choice Summary of Benefits and Coverage
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Choice Subscriber Certificate
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Choice Dental
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Value Benefit Summary
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Value Summary of Benefits and Coverage
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Silver Value Subscriber Certificate
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Bronze Value Dental
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Bronze Value Benefit Summary
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Bronze Value Summary of Benefits and Coverage
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Bronze Value Subscriber Certificate
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Bronze Value Dental
2019 Direct from EmblemHealth (Non-standard)
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EmblemHealth Bronze Plus HSA Benefit Summary
2019 Direct from EmblemHealth (Standard)
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EmblemHealth Bronze Plus HSA Summary of Benefits and Coverage
2019 Direct from EmblemHealth (Standard)
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EmblemHealth Bronze Plus HSA Subscriber Certificate
2019 Direct from EmblemHealth (Standard)
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EmblemHealth Bronze Plus HSA Dental
2019 Direct from EmblemHealth (Standard)
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EmblemHealth Gold Open Access (with adult dental and vision) EmblemHealth Benefit Summary
2018 Direct from EmblemHealth (Nonstandard)
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EmblemHealth Gold Open Access (with adult dental and vision) Summary of Benefits and Coverage
2018 Direct from EmblemHealth (Nonstandard)
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EmblemHealth Gold Open Access (with adult dental and vision) Dental Benefits Summaries
2018 Direct from EmblemHealth (Nonstandard)
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EmblemHealth Gold Open Access (with adult dental and vision) Subscriber Certificate
2018 Direct from EmblemHealth (Nonstandard)
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EmblemHealth Gold Open Access (with adult dental and vision) Plan Formulary (list of covered drugs)
2018 Direct from EmblemHealth (Nonstandard)
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EmblemHealth Silver Value (with adult dental and vision) EmblemHealth Benefit Summary
2018 Direct from EmblemHealth (Nonstandard)
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EmblemHealth Silver Value (with adult dental and vision) Summary of Benefits and Coverage
2018 Direct from EmblemHealth (Nonstandard)
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EmblemHealth Silver Value (with adult dental and vision) Dental Benefits Summaries
2018 Direct from EmblemHealth (Nonstandard)
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EmblemHealth Silver Value (with adult dental and vision) Subscriber Certificate
2018 Direct from EmblemHealth (Nonstandard)
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EmblemHealth Silver Value (with adult dental and vision) Plan Formulary (list of covered drugs)
2018 Direct from EmblemHealth (Nonstandard)
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EmblemHealth Bronze Value (with adult dental and vision) EmblemHealth Benefit Summary
2018 Direct from EmblemHealth (Nonstandard)
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EmblemHealth Bronze Value (with adult dental and vision) Summary of Benefits and Coverage
2018 Direct from EmblemHealth (Nonstandard)
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EmblemHealth Bronze Value (with adult dental and vision) Subscriber Certificate
2018 Direct from EmblemHealth (Nonstandard)
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EmblemHealth Bronze Value (with adult dental and vision) Plan Formulary (list of covered drugs)
2018 Direct from EmblemHealth (Nonstandard)
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EmblemHealth HMO 40/60 (Gold) EmblemHealth Benefit Summary
2018 Direct from EmblemHealth (Nonstandard)
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EmblemHealth HMO 40/60 (Gold) Summary of Benefits and Coverage
2018 Direct from EmblemHealth (Nonstandard)
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EmblemHealth HMO 40/60 (Gold) Subscriber Certificate
2018 Direct from EmblemHealth (Nonstandard)
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EmblemHealth HMO 40/60 (Gold) Plan Formulary (list of covered drugs)
2018 Direct from EmblemHealth (Nonstandard)
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EmblemHealth HMO 15/35 (Platinum) Benefit Summary
2018 Direct from EmblemHealth (Standard)
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EmblemHealth HMO 15/35 (Platinum) Summary of Benefits and Coverage
2018 Direct from EmblemHealth (Standard)
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EmblemHealth HMO 15/35 (Platinum) Subscriber Certificate
2018 Direct from EmblemHealth (Standard)
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EmblemHealth HMO 15/35 (Platinum) Plan Formulary (list of covered drugs)
2018 Direct from EmblemHealth (Standard)
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EmblemHealth Bronze HSA Benefit Summary
2018 Direct from EmblemHealth (Standard)
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EmblemHealth Bronze HSA Summary of Benefits and Coverage
2018 Direct from EmblemHealth (Standard)
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EmblemHealth Bronze HSA Subscriber Certificate
2018 Direct from EmblemHealth (Standard)
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EmblemHealth Bronze HSA Plan Formulary (list of covered drugs)
2018 Direct from EmblemHealth (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).
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2020 Child Health Plus Formulary
This is a list of the most commonly prescribed preferred drugs for members with the Child Health Plus Formulary (Effective April 1, 2020).
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2020 Enhanced Care (Medicaid) and Enhanced Care Plus (HARP) Formulary
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. Some sections of your member handbook have been updated. For information about the changes refer to the inserts at the end of the member handbook.
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Enhanced Care (Medicaid)
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Enhanced Care Plus (HARP)
Find a doctor or medical office
Find a doctor or medical office
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© 2020 EmblemHealth. All Rights Reserved.
Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.
Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.