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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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
EPO Qualified Health
HMO Millennium
HMO Qualified Health
HMO Qualified Health with Acupuncture
HMO Select Care
PPO Qualified Health
ConsumerDirect EPO
ConsumerDirect PPO
EPO
EPO Value
EPO Value HDHP (High Deductible Health Plan)
GHI HMO
Health Essentials Plus EPO
HIP HMO Preferred
HIP Prime HMO
HIP Prime POS
HIP Prime PPO
HIP Select PPO
HIPaccess I
HIPaccess II
HMO Plus
HMO Preferred Plus
InBalance EPO
InBalance PPO
PPO
PPO Value
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
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
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)
Preauthorization Check Tool
EmblemHealth is offering an easy way for you to see if your procedure requires preauthorization.
It’s a Preauthorization Check tool for members who have our HMO plans. Before using the tool, ask your doctor for the Procedure Code, also known as CPT or HCPCS code, and your Diagnosis code and Place of Service code—where the services will be performed. Once you have this information, click on the Preauthorization Check button below. Enter the information to see if you need to get a preauthorization ahead of your procedure.
Remember, you never have to get a preauthorization for emergency services.
If you have a PPO plan or if you have other questions, you can always check your plan documents, or call the number on your ID card.
