Forms and documents

Member materials 

• 2020 PMAP/MNCare provider directory (PDF)
• 2020 SNBC provider directory (PDF)
• 2021 PMAP/MNCare provider directory - effective 1/1/2021 (PDF)
• 2021 SNBC provider directory - effective 1/1/2021 (PDF) 

• Drug list (Formulary) - effective 7/1/2020 (PDF)
• 2020 list of covered drugs for SNBC members with Medicare coverage (Formulary) – effective 7/1/2020 (PDF)

• Prior authorization chart (DOCX) 

• PMAP member handbook (PDF)
• MNCare member handbook (PDF)
• 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