Forms & Documents

Member Handbook

Covered Services

Medicaid Managed Care Formulary

Institution for Mental Disease (IMD) In Lieu of Service (ILS) Benefit

Member Handbook

Covered Services

Personal Wellness Plan Formulary

Institution for Mental Disease (IMD) In Lieu of Service (ILS) Benefit

Member Handbook

Covered Services

Child Health Plus Formulary

Member Complaint Form

Physician Nomination Form

Member Status Change Form

What You Need to Know About HIV Testing

Authorization to Release Protected Health Information

Authorization to Release Substance Use Disorder Protected Health

New York State Privacy Notice

Member Handbook

Summary of Benefits - Essential Plan 1

Summary of Benefits - Essential Plan 1 Plus Dental & Vision

Essential Plan Formulary

Member Handbook

Summary of Benefits - Essential Plan 2

Summary of Benefits - Essential Plan 2 Plus Dental & Vision

Essential Plan Formulary

Member Handbook

Summary of Benefits - Essential Plan 3

Essential Plan Formulary

Member Handbook

Summary of Benefits - Essential Plan 4

Essential Plan Formulary

Physician Nomination Form

CVS Mail Service Order Form

Gym Benefits - Visit Submission Form

Essential Plan Member Reimbursement Instruction and Form

Authorization to Release Protected Health Information

Authorization to Release Substance Use Disorder Protected Health Information

New York State Privacy Notice

Member Handbook

Summary of Benefits - Platinum Leaf Premier Plan

Summary of Benefits - Platinum Leaf Plan

Leaf and Leaf Premier Plan Formulary

Member Handbook

Summary of Benefits - Gold Leaf Premier Plan

Summary of Benefits - Gold Leaf Plan

Leaf and Leaf Premier Plan Formulary

Member Handbook

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

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

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

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

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

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

Leaf and Leaf Premier Plan Formulary

Member Handbook

Summary of Benefits - Bronze Leaf Premier Plan

Summary of Benefits - Bronze Leaf Plan

Leaf and Leaf Premier Plan Formulary

Member Handbook

Summary of Benefits - Green Leaf Plan

Leaf and Leaf Premier Plan Formulary

Physician Nomination Form

CVS Mail Service Order Form

Gym Benefits - Visit Submission Form

Leaf Plan Member Reimbursement Instruction and Form

Authorization to Release Protected Health Information

Authorization to Release Substance Use Disorder Protected Health Information

New York State Privacy Notice

Member Handbook

Summary of Benefits - Platinum Total EPO

Total EPO Plan Formulary

Member Handbook

Summary of Benefits - Gold Total EPO

Total EPO Plan Formulary

Member Handbook

Summary of Benefits - Silver Total EPO

Total EPO Plan Formulary

Member Handbook

Summary of Benefits - Bronze Total EPO

Total EPO Plan Formulary

Physician Nomination Form

CVS Mail Service Order Form

Gym Benefits - Visit Submission Form

Authorization to Release Protected Health Information

Authorization to Release Substance Use Disorder Protected Health Information

New York State Privacy Notice

Member Handbook

Covered Services

Medicaid Managed Care Formulary

Member Handbook

Covered Services

Personal Wellness Plan Formulary

Member Handbook

Covered Services

Child Health Plus Formulary

Member Complaint Form

Physician Nomination Form

Member Status Change Form

What You Need to Know About HIV Testing

Authorization to Release Protected Health Information

Authorization to Release Substance Use Disorder Protected Health

New York State Privacy Notice

Member Handbook

Summary of Benefits - Essential Plan 1

Summary of Benefits - Essential Plan 1 Plus Dental & Vision

Essential Plan Formulary

Member Handbook

Summary of Benefits - Essential Plan 2

Summary of Benefits - Essential Plan 2 Plus Dental & Vision

Essential Plan Formulary

Member Handbook

Summary of Benefits - Essential Plan 3

Essential Plan Formulary

Member Handbook

Summary of Benefits - Essential Plan 4

Essential Plan Formulary

Physician Nomination Form

CVS Mail Service Order Form

Gym Benefits - Visit Submission Form

Essential Plan Member Reimbursement Instruction and Form

Authorization to Release Protected Health Information

Authorization to Release Substance Use Disorder Protected Health Information

New York State Privacy Notice

Member Handbook

Summary of Benefits - Platinum Leaf Premier Plan

Summary of Benefits - Platinum Leaf Plan

Leaf and Leaf Premier Plan Formulary

Member Handbook

Summary of Benefits - Gold Leaf Premier Plan

Summary of Benefits - Gold Leaf Plan

Leaf and Leaf Premier Plan Formulary

Member Handbook

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

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

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

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

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

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

Leaf and Leaf Premier Plan Formulary

Member Handbook

Summary of Benefits - Bronze Leaf Premier Plan

Summary of Benefits - Bronze Leaf Plan

Leaf and Leaf Premier Plan Formulary

Member Handbook

Summary of Benefits - Green Leaf Plan

Leaf and Leaf Premier Plan Formulary

Physician Nomination Form

CVS Mail Service Order Form

Gym Benefits - Visit Submission Form

Leaf Plan Member Reimbursement Instruction and Form

Authorization to Release Protected Health Information

Authorization to Release Substance Use Disorder Protected Health Information

New York State Privacy Notice

Member Handbook

Summary of Benefits - Platinum Total EPO

Total EPO Plan Formulary

Member Handbook

Summary of Benefits - Gold Total EPO

Total EPO Plan Formulary

Member Handbook

Summary of Benefits - Silver Total EPO

Total EPO Plan Formulary

Member Handbook

Summary of Benefits - Bronze Total EPO

Total EPO Plan Formulary

Physician Nomination Form

CVS Mail Service Order Form

Gym Benefits - Visit Submission Form

Authorization to Release Protected Health Information

Authorization to Release Substance Use Disorder Protected Health Information

New York State Privacy Notice

Comprehensive Formulary

Annual Notice of Changes

Evidence of Coverage

Summary of Benefits

OTC Reimbursement Form

Comprehensive Formulary

Annual Notice of Changes

Evidence of Coverage

Summary of Benefits

Comprehensive Formulary

Annual Notice of Changes

Evidence of Coverage

Summary of Benefits

Annual Notice of Changes

Evidence of Coverage

Summary of Benefits

Comprehensive Formulary

Annual Notice of Changes

Evidence of Coverage

Summary of Benefits

Member Handbook

OTC/Grocery Reimbursement Form

Member Handbook

Appointments of Representative Form

Member Reimbursement Form

CVS Mail Service Order Form

OTC Reimbursement Form

Post Discharge Meal Request Form

Post Discharge Meal Request FAQ

2020 Star Ratings

Regulation 194 - Disclosure

Part D Coverage Determination Form

Part D Redetermination Request Form

Enrollment Form

Short Enrollment Form

Pre-Enrollment Checklist

Authorization to Release Protected Health Information

Authorization to Release Substance Use Disorder Protected Health Information

New York State Privacy Notice

Federal Privacy Notice

Notice of Non-Discrimination

Comprehensive Formulary

Annual Notice of Changes

Evidence of Coverage

Summary of Benefits

Comprehensive Formulary

Annual Notice of Changes

Evidence of Coverage

Summary of Benefits

Comprehensive Formulary

Annual Notice of Changes

Evidence of Coverage

Summary of Benefits

Annual Notice of Changes

Evidence of Coverage

Summary of Benefits

Comprehensive Formulary

Annual Notice of Changes

Evidence of Coverage

Summary of Benefits

Member Handbook

Comprehensive Formulary

Annual Notice of Changes

Summary of Benefits

Participant Handbook

Appointment of Representative Form

Member Reimbursement Form

CVS Mail Service Order Form

OTC Reimbursement Form

Post-Hospitalization Meals Request Form

2019 Star Ratings

Part D Coverage Determination Form

Part D Redetermination Request Form

Enrollment Form

Short Enrollment Form

Pre-Enrollment Checklist

Authorization to Release Protected Health Information

Authorization to Release Substance Use Disorder Protected Health Information

New York State Privacy Notice

Federal Privacy Notice

Notice of Non-Discrimination

Member Handbook

Summary of Benefits - Platinum Pro Plus EPO

Summary of Benefits - Platinum Pro EPO

Pro and Pro Plus EPO Plan Formulary

Member Handbook

Summary of Benefits - Gold Pro Plus EPO

Summary of Benefits - Gold 25/50/0 Pro Plus EPO

Summary of Benefits - Gold Pro EPO

Summary of Benefits - Gold 25/50/0 Pro EPO

Pro and Pro Plus EPO Plan Formulary

Member Handbook

Summary of Benefits - Silver Pro Plus EPO

Summary of Benefits - Silver 40/75/4700 Pro Plus EPO

Summary of Benefits - Silver Pro EPO

Summary of Benefits - Silver 40/75/4700 Pro EPO

Pro and Pro Plus EPO Plan Formulary

Member Handbook

Summary of Benefits - Bronze Pro Plus EPO

Summary of Benefits - Bronze 6650 Pro Plus EPO

Summary of Benefits - Bronze Pro EPO

Summary of Benefits - Bronze 6650 Pro EPO

Summary of Benefits - Bronze 8150 Pro EPO

Pro and Pro Plus EPO Plan Formulary

Member Handbook

Summary of Benefits - Platinum Pro Plus EPO

Summary of Benefits - Platinum Pro EPO

Pro and Pro Plus EPO Plan Formulary

Member Handbook

Summary of Benefits - Gold Pro Plus EPO

Summary of Benefits - Gold 25/50/0 Pro Plus EPO

Summary of Benefits - Gold Pro EPO

Summary of Benefits - Gold 25/50/0 Pro EPO

Pro and Pro Plus EPO Plan Formulary

Member Handbook

Summary of Benefits - Silver Pro Plus EPO

Summary of Benefits - Silver 40/75/4700 Pro Plus EPO

Summary of Benefits - Silver Pro EPO

Summary of Benefits - Silver 40/75/4700 Pro EPO

Pro and Pro Plus EPO Plan Formulary

Member Handbook

Summary of Benefits - Bronze Pro Plus EPO

Summary of Benefits - Bronze 6650 Pro Plus EPO

Summary of Benefits - Bronze Pro EPO

Summary of Benefits - Bronze 6650 Pro EPO

Pro and Pro Plus EPO Plan Formulary