Plan Documents and Forms (2013)

» Peoples Health Choices 65 (HMO)
» Peoples Health Choices Plus (HMO)
» Peoples Health Choices Select (HMO)
» Peoples Health Secure Choice (HMO SNP)
» Peoples Health Secure Health (HMO SNP)
» Peoples Health Group Medicare for OGB (HMO-POS)
» Peoples Health Group Medicare Gold (HMO-POS)
» PHN Employee Plan
» Important Documents, Links and Forms

Peoples Health Choices 65 (HMO)

Quick Guide
Download PDF (2.4 MB) | View Document Online

Summary of Benefits
Download PDF (532 KB) | View Document Online

Evidence of Coverage
Download PDF (1.7 MB) | View Document Online

Abridged Formulary
Download PDF (2.3 MB) | View Document Online

Abridged Formulary Addendum
Last updated: February 1, 2013
Download PDF (49.5 KB)

Provider Directory
Download PDF (7.5 MB) | View Document Online

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Peoples Health Choices Plus (HMO)

Quick Guide
Download PDF (2.4 MB) | View Document Online

Summary of Benefits
Download PDF (532 KB) | View Document Online

Evidence of Coverage
Download PDF (1.5 MB) | View Document Online

Abridged Formulary
Download PDF (2.3 MB) | View Document Online

Abridged Formulary Addendum
Last updated: February 1, 2013
Download PDF (49.5 KB)

Provider Directory
Download PDF (6.8 MB) | View Document Online

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Peoples Health Choices Select (HMO)

Quick Guide
Download PDF (2.4 MB) | View Document Online

Summary of Benefits
Download PDF (532 KB) | View Document Online

Evidence of Coverage
Download PDF (1.3 MB) | View Document Online

Abridged Formulary
Download PDF (2.3 MB) | View Document Online

Abridged Formulary Addendum
Last updated: February 1, 2013
Download PDF (49.5 KB)

Provider Directory
Download PDF (6.7 MB) | View Document Online

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Peoples Health Secure Choice (HMO SNP)

Quick Guide
Download PDF (2.4 MB)| View Document Online

Summary of Benefits
Download PDF (407 KB) | View Document Online

Evidence of Coverage
Download PDF (1.4 MB) | View Document Online

Abridged Formulary
Download PDF (2.3 MB) | View Document Online

Abridged Formulary Addendum
Last updated: February 1, 2013
Download PDF (49.5 KB)

Provider Directory
Download PDF (7.8 MB) | View Document Online

Top Of Page

Peoples Health Secure Health (HMO SNP)

Quick Guide
Download PDF (2.4 MB)| View Document Online

Summary of Benefits
Download PDF (407 KB) | View Document Online

Evidence of Coverage
Download PDF (1.4 MB) | View Document Online

Abridged Formulary
Download PDF (2.3 MB) | View Document Online

Abridged Formulary Addendum
Last updated: February 1, 2013
Download PDF (49.5 KB)

Provider Directory
Download PDF (6.7 MB) | View Document Online

Top Of Page

Peoples Health Group Medicare for OGB (HMO-POS)

Quick Guide
Download PDF (425 KB) | View Document Online

Evidence of Coverage
Download PDF (1.7 MB)| View Document Online

Abridged Formulary
Download PDF (2.3 MB) | View Document Online

Abridged Formulary Addendum
Last updated: February 1, 2013
Download PDF (49.5 KB)

Provider Directory
Download PDF (10.7 MB) | View Document Online

Top Of Page

Peoples Health Group Medicare (HMO-POS)

Quick Guide
Download PDF (450 KB) | View Document Online

Evidence of Coverage
Download PDF (1.5 MB) | View Document Online

Abridged Formulary
Download PDF (2.3 MB) | View Document Online

Abridged Formulary Addendum
Last updated: February 1, 2013
Download PDF (49.5 KB)

Provider Directory
Download PDF (10.7 MB) | View Document Online

Top Of Page

PHN Employee Plan

Summary of Benefits and Coverage - Explains PHN Employee Plan coverage levels and costs when accessing health services and filling prescriptions.
Download PDF (205 KB) | View Document Online

Plan Document and Summary Plan Description - Provides information about PHN Employee Plan benefits, membership, covered and non-covered services, member rights and responsibilities and other important plan details.
Download PDF (640 KB) | View Document Online

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Important Documents, Links and Forms

2013 - Comprehensive Formulary
Download PDF (11.5 MB)

Prior Authorization Criteria - describes prior authorization requirements for select drugs on the Peoples Health formulary
Download PDF (180 KB)

Step Therapy Criteria - describes step therapy criteria for select drugs on the Peoples Health formulary Download PDF (55 KB)

Department of Veterans Affairs Request for and Authorization to Release Medical Records - Department of Veterans Affairs Request for and Authorization to Release Medical Records or Health Information.
Download PDF (426 KB)

Notice of Privacy Practices - describes how your medical information may be used and disclosed and how you can get access to this information.
Download PDF (588 KB) | View Document Online

Appointment of Representative Form
Download PDF (72 KB)

Grievance or Complaint Form
Online Form

Mail-Order Prescription Drug Form
Download PDF (339 KB)

Pharmacy Request Form - a form for you and your doctor to complete if your doctor would like to request an exception to the Peoples Health formulary
Download PDF (124 KB)

Request for an Appeal or Redetermination Form
Online Form

Request for Medicare Prescription Drug Coverage Determination Form
Download PDF (28 KB)

Request for Redetermination of Medicare Prescription Drug Denial Form
Download PDF (90 KB)

Request for Medicare Prescription Drug Coverage Determination Form
Online Form

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