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Forms & Documents

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Viewing documents for:

Medicaid Plans

Plan Documents

Essential Plan 1
Medicaid Managed Care

Member Handbook

English Español 中文

Covered Services

English

Formulary Change Alert

English

Medicaid Managed Care Formulary

English
Institution for Mental Disease (IMD) In Lieu of Service (ILS) Benefit
Personal Wellness Plan

Member Handbook

English Español 中文

Covered Services

English

Formulary Change Alert

English

Personal Wellness Plan Formulary

English
Institution for Mental Disease (IMD) In Lieu of Service (ILS) Benefit
Child Health Plus

Member Handbook

English Español 中文

Covered Services

English

Child Health Plus Formulary

English
Member Resources
Privacy and Protected Health Information (PHI)
Essential Plan 2
Essential Plan 3
Essential Plan 4
Platinum
Gold
Silver
Bronze
Green

General Forms, Documents, and Resources

Essential Plan 1
Medicaid Managed Care
Personal Wellness Plan
Child Health Plus
Member Resources

Member Complaint Form

English Español 中文

Member Status Change Form

English Español 中文

What You Need to Know About HIV Testing

English Español 中文
Privacy and Protected Health Information (PHI)

Authorization to Release Protected Health Information

English Español 中文

Authorization to Release Substance Use Disorder Protected Health

English Español 中文

Healthfirst's Privacy Notice

English Español 中文
Essential Plan 2
Essential Plan 3
Essential Plan 4
Platinum
Gold
Silver
Bronze
Green

Essential Plans

Plan Documents

Essential Plan 1

Member Handbook

English Español 中文 русский

Summary of Benefits - Essential Plan 1

English Español 中文

Summary of Benefits - Essential Plan 1 Plus Dental & Vision

English Español 中文

Essential Plan Formulary

English
Medicaid Managed Care
Personal Wellness Plan
Child Health Plus
Member Resources
Privacy and Protected Health Information (PHI)
Essential Plan 2

Member Handbook

English Español 中文 русский

Summary of Benefits - Essential Plan 2

English Español 中文

Summary of Benefits - Essential Plan 2 Plus Dental & Vision

English Español 中文

Essential Plan Formulary

English
Essential Plan 3

Member Handbook

English Español 中文 русский

Summary of Benefits - Essential Plan 3

English Español 中文

Essential Plan Formulary

English
Essential Plan 4

Member Handbook

English Español 中文 русский

Summary of Benefits - Essential Plan 4

English Español 中文

Essential Plan Formulary

English
Platinum
Gold
Silver
Bronze
Green

General Forms, Documents, and Resources

Essential Plan 1
Medicaid Managed Care
Personal Wellness Plan
Child Health Plus
Member Resources

CVS Mail Service Order Form

English Español

Gym Benefits - Visit Submission Form

English Español 中文

Essential Plan Member Reimbursement Instruction and Form

English Español 中文
Privacy and Protected Health Information (PHI)

Authorization to Release Protected Health Information

English Español 中文

Authorization to Release Substance Use Disorder Protected Health Information

English Español 中文

Healthfirst's Privacy Notice

English Español 中文
Essential Plan 2
Essential Plan 3
Essential Plan 4
Platinum
Gold
Silver
Bronze
Green

Leaf and Leaf Premier Plans

Plan Documents

Essential Plan 1
Medicaid Managed Care
Personal Wellness Plan
Child Health Plus
Member Resources
Privacy and Protected Health Information (PHI)
Essential Plan 2
Essential Plan 3
Essential Plan 4
Platinum

Member Handbook

English Español 中文 русский

Summary of Benefits - Platinum Leaf Premier Plan

English Español 中文

Summary of Benefits - Platinum Leaf Plan

English Español 中文

Leaf and Leaf Premier Plan Formulary

English
Gold

Member Handbook

English Español 中文 русский

Summary of Benefits - Gold Leaf Premier Plan

English Español 中文

Summary of Benefits - Gold Leaf Plan

English Español 中文

Leaf and Leaf Premier Plan Formulary

English
Silver

Member Handbook

English Español 中文 русский

Summary of Benefits - Silver Leaf Premier Plan (>250% FPL)

English Español 中文

Summary of Benefits - Silver Leaf Premier Plan (200 - 250% FPL)

English Español 中文

Summary of Benefits - Silver Leaf Plan (>250% FPL)

English Español 中文

Summary of Benefits - Silver Leaf Plan (200 - 250% FPL)

English Español 中文

Summary of Benefits - Silver Leaf Plan (150 - 200% FPL)

English Español 中文

Summary of Benefits - Silver Leaf Plan (100 - 150% FPL)

English Español 中文

Leaf and Leaf Premier Plan Formulary

English
Bronze

Member Handbook

English Español 中文 русский

Summary of Benefits - Bronze Leaf Premier Plan

English Español 中文

Summary of Benefits - Bronze Leaf Plan

English Español 中文

Leaf and Leaf Premier Plan Formulary

English
Green

Member Handbook

English Español 中文 русский

Summary of Benefits - Green Leaf Plan

English Español 中文

Leaf and Leaf Premier Plan Formulary

English

General Forms, Documents, and Resources

Essential Plan 1
Medicaid Managed Care
Personal Wellness Plan
Child Health Plus
Member Resources

CVS Mail Service Order Form

English English

Gym Benefits - Visit Submission Form

English Español 中文

Leaf Plan Member Reimbursement Instruction and Form

English Español 中文
Privacy and Protected Health Information (PHI)

Authorization to Release Protected Health Information

English Español 中文

Authorization to Release Substance Use Disorder Protected Health Information

English Español 中文

Healthfirst's Privacy Notice

English Español 中文
Essential Plan 2
Essential Plan 3
Essential Plan 4