Plan Documents and Forms (2012)

Looking for 2011 Plan Documents? Click here.

The following documents contain information on services covered by 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 (HMO-POS) and PHN Employee Plan. They also define member benefits and covered services as well as member rights and responsibilities.  

Evidence of Coverage Documents

Peoples Health Choices 65 (HMO)
Download PDF (3.4 MB)

Peoples Health Choices Plus (HMO-POS)
Download PDF (3.5 MB)

Peoples Health Choices Select (HMO-POS)
Download PDF (3.5 MB)

Peoples Health Secure Health (HMO SNP)
Download PDF (3.4 MB)

Peoples Health Group Medicare for OGB (HMO-POS)
Download PDF (3.4 MB)

Peoples Health Group Medicare Gold (HMO-POS)
Download PDF (3.4 MB)

Certificate of Coverage

PHN Employee Plan
(Coming Soon)

Summary of Benefits

The following documents provides a summary of plan benefits and services.

Peoples Health Choices 65 (HMO)
Peoples Health Choices Plus (HMO-POS)
Peoples Health Choices Select (HMO-POS)
Download PDF (455 KB)

Peoples Health Secure Health (HMO SNP)
Download PDF (593 KB)

PHN Employee Plan
(Coming Soon)

Abridged Formulary and Pharmacy Request Form

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

Peoples Health Choices 65 (HMO)
Download PDF (1.5 MB)
Addendum—last updated: March 2012
Download PDF (160 KB)

Peoples Health Choices Plus (HMO-POS)
Peoples Health Choices Select (HMO-POS)
Peoples Health Secure Health (HMO SNP)
Download PDF (1.5 MB)
Addendum—last updated: March 2012
Download PDF (164 KB)

Peoples Health Group Medicare (HMO-POS)
Download PDF (1.5 MB)
Addendum—last updated: March 2012
Download PDF (160 KB)

For the most up-to-date information on the drugs covered by our formulary, including any utilization requirements that apply, use our Prescription Search tool.

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

Pharmacy Request Form
Download PDF (485 KB)

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 Agency Update/Recertification Form
Download PDF (32 KB)

Medical Necessity Form and Authorization Requirements Search

Medical Necessity Form - This form is used to determine medical necessity and to ensure that requested services are covered.
Download PDF (939 KB)

Authorization Requirements Search - A detailed list of procedures that require an authorization is located on the back of the Medical Necessity Form. There are some exceptions to this listing, which can be determined by using the Authorization Requirements Search. You can search the database by selecting a place of service code and inputting a CPT code to determine if the procedure requires prior authorization.

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