Plan Documents and Forms (2012)

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

Peoples Health Choices 65 (HMO)

Quick Guide
Download PDF (2 MB)

Summary of Benefits
Download PDF (455 KB)

Evidence of Coverage
Download PDF (3.4 MB)

Abridged Formulary
Download PDF (1.5 MB)

Provider Directory
Download PDF (3.1 MB)

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Peoples Health Choices Plus (HMO-POS)

Quick Guide
Download PDF (2 MB)

Summary of Benefits
Download PDF (455 KB)

Evidence of Coverage
Download PDF (3.4 MB)

Abridged Formulary
Download PDF (1.5 MB)

Provider Directory
Download PDF (3.5 MB)

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Peoples Health Choices Select (HMO-POS)

Quick Guide
Download PDF (2 MB)

Summary of Benefits
Download PDF (455 KB)

Evidence of Coverage
Download PDF (3.4 MB)

Abridged Formulary
Download PDF (1.5 MB)

Provider Directory
Download PDF (3.5 MB)

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Peoples Health Secure Health (HMO SNP)

Quick Guide
Download PDF (2 MB)

Summary of Benefits
Download PDF (455 KB)

Evidence of Coverage
Download PDF (3.4 MB)

Abridged Formulary
Download PDF (1.5 MB)

Provider Directory
Download PDF (3.5 MB)

Top Of Page

Peoples Health Group Medicare for OGB (HMO-POS)

Quick Guide
Download PDF (2 MB)

Evidence of Coverage
Download PDF (3.4 MB)

Abridged Formulary
Download PDF (1.5 MB)

Provider Directory
Download PDF (3.6 MB)

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Peoples Health Group Medicare (HMO-POS)

Quick Guide
Download PDF (2 MB)

Evidence of Coverage
Download PDF (3.4 MB)

Abridged Formulary
Download PDF (1.5 MB)

Provider Directory
Download PDF (3.6 MB)

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Important Documents, Links and Forms

Comprehensive Formulary - Peoples Health Choices 65 (HMO)
Download PDF (1 MB)

Comprehensive Formulary - Peoples Health Choices Plus (HMO-POS), Peoples Health Choices Select (HMO-POS) and Peoples Health Secure Health (HMO SNP)
Download PDF (1 MB)

Comprehensive Formulary - Peoples Health Group Medicare (HMO-POS)
Download PDF (1 MB)

Prior Authorization Criteria - describes prior authorization requirements for select drugs on the Peoples Health formulary
Download PDF (455 KB)

Step Therapy Criteria - describes step therapy criteria for select drugs on the Peoples Health formulary
Download PDF (266 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)

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)

Appointment of Representative Form
Download PDF (66 KB)

Grievance or Complaint Form
Online Form

Mail-Order Prescription Drug Form
Download PDF (267 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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