Forms/documents

Member materials 

• PMAP/MinnesotaCare provider directory - effective 11/1/2024: English (PDF)  Español (PDF)
• SNBC provider directory - effective 11/1/2024: English (PDF)  Español (PDF) 

• List of covered drugs (Formulary) - effective 12/1//2024 (PDF)
• List of covered drugs (Formulary) - effective 1/1//2025 (PDF)
• List of covered drugs for SNBC members with Medicare coverage - effective 6/1/2024 (PDF)
• List of covered drugs for SNBC members with Medicare coverage - effective 1/1/2025 (PDF)

• Prior authorization chart (PDF)

• 2024 PMAP member handbook (PDF)
• 2024 MinnesotaCare member handbook (PDF)
• 2024 SNBC member handbook (PDF)

Forms

• Member information release form (PDF)

• Member appeal and complaints (grievances) form (PDF)

• Request for protected health information form (PDF) 

• Change to protected health information form (PDF)

• Request for personal health information disclosures form (PDF) 

Rewards vouchers

• Adolescent immunization:  English (PDF) Af Soomaali (PDF)  Español (PDF)
• Annual blood glucose test - A1C:  English (PDF)  Af Soomaali (PDF)  Español (PDF)
• Annual dental visit:  English (PDF)  Af Soomaali (PDF)  Español (PDF)  
• Annual eye exam:  English (PDF)  Af Soomaali (PDF)  Español (PDF)
• Cervical cancer screening:  English (PDF)  Af Soomaali (PDF)  Español (PDF) 
• Child & Teen Checkup six visits; 0-14 months:  English (PDF)  Af Soomaali (PDF)  Español (PDF)
• Child & Teen Checkup visits; 15 months–17 years:  English (PDF)  Af Soomaali (PDF)  Español (PDF) 
• Colorectal cancer screening: English (PDF)  Af Soomaali (PDF)  Español (PDF)
• Early childhood immunizations:  English (PDF)  Af Soomaali (PDF)  Español (PDF)
• Mammogram screening:  English (PDF)  Af Soomaali (PDF)  Español (PDF) 
• Pregnancy prenatal visit:  English (PDF)  Af Soomaali (PDF)  Español (PDF) 
• Pregnancy postpartum visit:  English (PDF)  Af Soomaali (PDF)  Español (PDF) 
• Young adult checkup visits:  English (PDF)  Af Soomaali (PDF)  Español (PDF) 

• Car seat program FAQ (PDF)

Notices

• Advance health care directive (ages 18+)
• Restricted Recipient Program (PDF)

• Members have a Bill of Rights pursuant to Minnesota Statutes, Section 62D.07, subdivision 3. You can read your Bill of Rights in your member handbook.

• Nondiscrimination notice
• Notice of privacy practices (PDF)
• Language and civil rights notices: English (PDF)  Hmong (PDF)  Somali (PDF) Spanish (PDF)
• Rights and safety with third-party health information apps
• Limited English Proficiency (LEP) plan (PDF) 

DHS approved: 9/24/2020, HC-1110-MC; 2/27/23, QM-1417-MC