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Forms and documents

Member materials 

  • PMAP/MNCare provider directory - effective 1/1/2021 (PDF)
  • SNBC provider directory - effective 1/1/2021 (PDF) 
  • Drug list (Formulary) - effective 1/1/2021 (PDF)
  • List of covered drugs for SNBC members with Medicare coverage (Formulary) – effective 7/1/2020 (PDF)
  • Prior authorization chart - effective 2021 (DOCX)
  • 2021 PMAP member handbook (PDF)
  • 2021 MNCare member handbook (PDF)
  • 2021 SNBC member handbook (PDF) 

Forms

  • Advance directive form (PDF) 
  • Patient authorization for release of information form (PDF)
  • Member appeal and complaints (grievances) form (PDF)

Rewards vouchers

  • Annual dental visit (PDF)
  • Cervical cancer screening (PDF)
  • Child & Teen Checkup visits: 0-14 months (PDF)
  • Child & Teen Checkup annual visit: 15 months – 21 years (PDF)
  • Diabetic blood glucose test - A1C (PDF)
  • Diabetic eye exam (PDF)
  • Mammogram screening (PDF)
  • Postpartum visit (PDF)
  • 1st prenatal visit (PDF)
  • 9 prenatal visits (PDF)
  • Car seat program FAQ (PDF)

Notices

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
  • Language and civil rights notices 

 

DHS approved 9/24/2020 ID# HC-1110-MC


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612-596-1036, TTY 1-800-627-3529

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