Documents and Forms

The following documents provide detailed information on Peoples Health Group Medicare (HMO-POS) plan benefits and plan information.

There are two different types of group Medicare plans offered by Peoples Health. One is a standard plan for employer groups. This plan is called Peoples Health Group Medicare Gold (HMO-POS). The other is a customized plan created for retirees with the Louisiana Office of Group Benefits (OGB); this plan is called Peoples Health Group Medicare for OGB (HMO-POS).

The plan documents for both of these plans are listed below.

If you would like any of the following documents mailed to you, please call us toll-free at (800) 978-9765, Monday through Friday, from 8 a.m. to 8 p.m. You should receive the documents within two weeks of your request.

Peoples Health Group Medicare for OGB (HMO-POS)

2010 Documents

• 2010 Abridged Formulary (OGB) (PDF file - 1.4 MB) - a partial list of the formulary of prescription drugs covered by Peoples Health Group Medicare for OGB (HMO-POS)
  
  
• 2010 Evidence of Coverage (OGB) (PDF file - 2.8 MB) - provides information about your benefits, membership, covered and non-covered services, member rights and responsibilities and other important plan details
  
  
• 2010 Provider Directory (OGB) (PDF file - 5.5 MB)
  
  
• Notice of Privacy Practices (PDF file - 588 KB) - describes how your medical information may be used and disclosed and how you can get access to this information
  
  
• Medicare Part D Tiering or Formulary Exception Request
  (PDF file - 28 KB)

2009 Documents

• 2009 Abridged Formulary (OGB) (PDF file - 4.9 MB) - a partial list of the formulary of prescription drugs covered by Peoples Health Group Medicare for OGB (HMO-POS)
  
  
• 2009 Evidence of Coverage (OGB) (PDF file - 1.9 MB) - provides information about your benefits, membership, covered and non-covered services, member rights and responsibilities and other important plan details
  
  
• 2009 Provider Directory (OGB) (PDF file - 6.9 MB)

• Amendment to 2009 Evidence of Coverage and Summary of Benefits
  (PDF file - 9 KB)
  
  

Peoples Health Group Medicare Gold (HMO-POS)

2010 Documents

• 2010 Abridged Formulary (PDF file - 1.4 MB) - a partial list of the open formulary for prescription drugs covered by Peoples Health Group Medicare (HMO-POS) for OGB
  
  
• 2010 Evidence of Coverage (PDF file - 2.9 MB) - provides information about your benefits, membership, covered and non-covered services, member rights and responsibilities and other important plan details
  
  
• 2010 Provider Directory (PDF file - 5.5 MB)
  
  
• Notice of Privacy Practices (PDF file - 588 KB) - describes how your medical information may be used and disclosed and how you can get access to this information
  
  
• Medicare Part D Tiering or Formulary Exception Request
  (PDF file - 28 KB)
  
  

2009 Documents

• 2009 Abridged Formulary (PDF file - 3.2 MB) - a partial list of the formulary of prescription drugs covered by Peoples Health Group Medicare Gold (HMO-POS)
  
  
• 2009 Evidence of Coverage (PDF file - 945 KB) - provides information about your benefits, membership, covered and non-covered services, member rights and responsibilities and other important plan details
  
  
• 2009 Provider Directory (PDF file - 8.5 MB)

• Amendment to 2009 Evidence of Coverage and Summary of Benefits
  (PDF file - 9 KB)
  

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