Plan Documents and Forms

Need more information?

The following documents provide detailed information on benefit and plan designs. Use the links below to view the documents directly from your computer.

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Coverage Documents

The following documents contain information on services covered by Choices 65 (HMO), Secure Health (HMO), Choices Plus (HMO-POS), Choice Select (HMO-POS), HealthCare Select and PHN Employee Plan. They also define member benefits and covered services as well as member rights and responsibilities.  

Choices 65 (HMO)

   2010 Evidence of Coverage (PDF file - 6.1 MB)

Choices Plus (HMO-POS)

   2010 Evidence of Coverage (PDF file - 6.1 MB)

Choices Select (HMO-POS)

   2010 Evidence of Coverage (PDF file - 6.1 MB)

Secure Health (HMO)

   2010 Evidence of Coverage (PDF file - 6.1 MB) 

Peoples Health Group Medicare (HMO-POS)

   2010 Evidence of Coverage (PDF file - 2.9 MB)

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

   2010 Evidence of Coverage (PDF file - 3 MB) 

PHN Employee Plan

   2010 Certificate of Coverage (will be available soon)
  2009 Certificate of Coverage (PDF file - 516 KB)

 

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Summary of Benefits

The following document provides a summary of plan benefits and services for

Choices 65 (HMO), Choices Plus (HMO-POS), Choices Select (HMO-POS) and Secure Health (HMO):
2010 Summary of Benefits (PDF file - 664 KB)

PHN Employee Plan:
2010 Summary of Benefits (PDF file - 112 KB)

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Abridged Formulary and Pharmacy Request Form

A partial list of the precription drugs covered by Peoples Health.

Choices 65 (HMO), Choices Plus (HMO-POS), Choices Select (HMO-POS) and Secure Health (HMO):
2010 Abridged Formulary (PDF file - 664 KB)

Choices Select (HMO-POS):
2010 Abridged Formulary (PDF file - 1.15 MB)

Peoples Health Group Medicare (HMO-POS):
2010 Abridged Formulary (PDF file - 1.41 MB)

You may use the Pharmacy Request Form to request formulary/tiering exceptions and to request prior authorization for prescription drugs.

Pharmacy Request Form (PDF file - 485 KB)

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Home Health Agency Update/Recertification Form

Use this form to provide Peoples Health with updates on home health services provided to our plan members, as well as to request recertification for services to be continued.

Home Health Update/Recertification Request Form (PDF file - 32 KB)

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Medical Necessity Form and Exceptions List 

• Medical Necessity Form (as of 1/1/2010) (PDF File - 692 KB) - This form is used to determine medical necessity and to ensure that requested services are covered.
• Authorization Exceptions List (as of 1/21/2010) (PDF file - 144 KB) - This list outlines, by category (e.g., Outpatient Surgical Procedures, DME, etc.) specific codes and procedures that do not require prior authorization.