Find benefit summaries, formularies (list of covered drugs), and all necessary forms to get the most out of your EmblemHealth coverage.
Looking for Medicare forms and documents?
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表格
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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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.
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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.
QuickStart 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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消费者直面 EPO
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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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安保健康保险晋级 EPO
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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 定点服务
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HIP SELECT PPO
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HIPaccess I
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HIPaccess II
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
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
承保药物清单
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2019 年基本健保计划药物名册
我们在纽约州官方健康保险的基本健保计划会员下涵承保的药物清单。It is up to date as of 2019年九月1日.
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2019 年合格健保计划药物名册
我们在纽约州官方健康保险的合格健保计划会员下涵承保的药物清单。It is up to date as of 2019年九月1日.
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2019 年大型团体药物名册
这是大型团体处方药（超过 50 种合格药物）的会员最常用的首选药物名册。
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2019 年小型团体药物名册
这是小型团体处方（生效日期：2019年7月1日）会员最常用的首选药物名册。
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2019 年儿童医保计划 CHPlus 药物名册
这是儿童医保计划 CHPlus （生效日期：2019年7月1日）的会员最常用的首选药物名册。
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.
查找医生或诊所
查找医生或诊所
访问安保健康保险门户
语言支持：
© 2019 安保健康保险。保留所有权利。
本网站提供的任何信息只作参考用途。它们不是医疗建议，也不应该取代与您的医疗服务提供方的定期会诊。如果您对您的健康有任何担忧，请联系您的医疗服务提供方的办公室。
此外，这些信息并不意味着信息中描述的服务或治疗是您的计划中的承保福利。请参考您的会员协议、承保范围证明、福利摘要、或其他计划文件，了解关于您的福利承保范围的具体信息。