Member Plan Documents and Forms | 2018

Access important 2018 plan documents and forms on this page.

If you are a plan member and would like any of the following documents mailed to you, please call member services at 504-849-4685225-346-5704 or toll-free 1-800-222-8600, seven days a week, from 8 a.m. to 8 p.m. TTY users may call 711. If you contact us on a weekend or holiday, you may need to leave a message, but we will return your call within one business day. You should receive the document within two weeks of your request.

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Plan Coverage Documents

Peoples Health Choices 65 #14 (HMO)

Plan Overview for Peoples Health Choices 65 #14 – An overview of plan benefits

Annual Notice of Changes for Peoples Health Choices 65 #14 – A summary of plan benefit changes compared to the previous year and other important plan details

Annual Notice of Changes for Peoples Health Choices Platinum #009 (HMO) – A summary of plan benefit changes compared to the previous year and other important plan details

Evidence of Coverage for Peoples Health Choices 65 #14 – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details

Summary of Benefits for Peoples Health Choices 65 #14 – A general summary of plan benefits

Peoples Health Choices 65 #14 (HMO) for St. Tammany Parish

Plan Overview for Peoples Health Choices 65 #14 for St. Tammany Parish – An overview of plan benefits

Annual Notice of Changes for Peoples Health Choices 65 #14 for St. Tammany Parish – A summary of plan benefit changes compared to the previous year and other important plan details

Evidence of Coverage for Peoples Health Choices 65 #14 for St. Tammany Parish – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details

Summary of Benefits for Peoples Health Choices 65 #14 for St. Tammany Parish – A general summary of plan benefits

Peoples Health Choices Gold (HMO)

Plan Overview for Peoples Health Choices Gold – An overview of plan benefits

Annual Notice of Changes for Peoples Health Choices Gold – A summary of plan benefit changes compared to the previous year and other important plan details

Evidence of Coverage for Peoples Health Choices Gold – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details

Summary of Benefits for Peoples Health Choices Gold – A general summary of plan benefits

Peoples Health Choices Select (HMO)

Plan Overview for Peoples Health Choices Select – An overview of plan benefits

Annual Notice of Changes for Peoples Health Choices Select – A summary of plan benefit changes compared to the previous year and other important plan details

Evidence of Coverage for Peoples Health Choices Select – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details

Summary of Benefits for Peoples Health Choices Select – A general summary of plan benefits

Peoples Health Group Medicare (HMO-POS)

Plan Overview for Peoples Health Group Medicare – An overview of plan benefits

Annual Notice of Changes for Peoples Health Group Medicare – A summary of plan benefit changes compared to the previous year and other important plan details

Evidence of Coverage for Peoples Health Group Medicare – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details

Peoples Health Group Medicare (HMO-POS) for Office of Group Benefits (OGB)

Plan Overview for Peoples Health Group Medicare for OGB – An overview of plan benefits

Annual Notice of Changes for Peoples Health Group Medicare for OGB – A summary of plan benefit changes compared to the previous year and other important plan details

Evidence of Coverage for Peoples Health Group Medicare for OGB – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details

Peoples Health Secure Choice #011 (HMO SNP)

Annual Notice of Changes for Peoples Health Secure Choice #011 – A summary of plan benefit changes compared to the previous year and other important plan details

Evidence of Coverage for Peoples Health Secure Choice #011 – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details

Summary of Benefits for Peoples Health Secure Choice #011 – A general summary of plan benefits

Other Important Documents, Links and Forms

Coverage Decisions, Appeals and Grievances

Appointment of Representative Form – To designate someone the right to act on your behalf as your representative for requesting a coverage decision or an appeal or making a grievance (complaint)

Request for Medicare Prescription Drug Coverage Determination Form – To request a decision on coverage of a prescription drug; you also have the option to request a coverage determination by completing a form through the Medicare website

Online form – Request for an Appeal Form – An online form to request an appeal for coverage of medical services or a prescription drug

Request for Redetermination of Medicare Prescription Drug Denial Form – To request reconsideration of our decision on how we will cover or pay for a prescription drug

Online form – Grievance or Complaint – An online form to make a complaint (grievance)

Prescription Drugs

2018 Medication Search Search medications online

2018 Comprehensive Formulary – A complete list of covered drugs

2018 Prior Authorization Criteria– Detailed criteria for select covered drugs

2018 Step Therapy Criteria – Detailed criteria for select covered drugs

Mail-Order Prescription Drug Form – For ordering eligible prescription drugs through the Peoples Health network mail-order pharmacy, CVS Caremark

Privacy

Department of Veterans Affairs Request for and Authorization to Release Medical Records – A form for requesting the release of your medical records or information from the Department of Veterans Affairs to Peoples Health

Notice of Privacy Practices – Description of how your medical information may be used and disclosed and how you can get access to this information