2022 PNMG Benefits

Medical Benefits

Benefits Matrix

• High Deductible Health Plan
• PPO Plan

Benefits Guide

• PNMG 2022 Benefit Guide

Summary of Benefits of coverage

• High Deductible Health Plan
• PPO Plan

SPDs

• High Deductible Health Plan
• PPO Plan

Legal

• Omnibus

Pharmacy

• Prescription Reimbursement Request Form
• High Deductible Health Plan
• Preventative Medications Not Subject to Deductible (HDHP only)
• PPO Plan
• 2022 Pharmacy Plan Formulary (PPO and HDHP)
• Zero Dollar Copay Medication List - PPO only

Forms

• Unavailable Service Request Form
• Medical Claim Form
• Coordination of Benefits
• General Disclosure Form

Health Equity Contact Information

Health Savings Account

• Call: 866-346-5800
• Visit: www.healthequity.com
• 24/7/365 support

Flexible Spending Account

• Call: 877-924-3967
• Visit: www.healthequity.com
• 24/7/365 support

Metlife Dental Contact Information

• Call: 800-275-4638
• Visit: www.metlife.com

VSP Vision Contact Information

• Call: 800-877-7195
• Visit: www.vsp.com

OptumRx Pharmacy/Prescription Contact Information

• Call: 866-868-1707
• Visit: www.OptumRx.com