skip to content
Peoples Health Your Medicare Health Team
  • Contact Us
  • Español
  • Home
  • About Us
  • Medicare Plans
  • For Members
  • For Providers
  • myHealth
  • Search Tools

Peoples Health Choices Select (HMO-POS)

Plan Details: Documents and Forms

Medicare Plans Home

Plan Overview

Plan Details

  • Appeals and Grievances
  • Benefits Overview
  • Coverage Decisions
  • Coverage Gap
  • Documents and Forms
  • Part D Coverage
  • Plan Premium

Provider Network

Eligibility and Enrollment

  • Eligibility Guidelines
  • How to Enroll
  • Online Enrollment Form
  • What to Expect Next

Need More Information?

Search Tools

  • Physician Search
  • Prescription Search
  • Hospital Search
  • View all Search Tools






  • PRINT
  • small text large text

Documents and Forms (2012)

Looking for 2011 plan documents? Click here.

The following documents provide detailed information on Peoples Health Choices Select (HMO-POS) benefits. Use the links below to view documents directly from your computer.

If you are a plan member and would like any of the following documents mailed to you, please call the Peoples Health Member Services department toll-free at(800) 222-8600, seven days a week, from 8 a.m. to 8 p.m., TTY users may call 711. If you contact Member Services on a weekend or on a holiday between February 15 and October 14, you may leave a message, and we will return your call within one business day. You should receive the document(s) within two weeks of your request.

Plan Documents

Quick Guide - an overview of plan benefits
PDF icon Download PDF (2 MB)

Abridged Formulary- a partial list of the formulary (the list of prescription drugs that Peoples Health covers)
PDF icon Download PDF (1.5 MB)
Addendum—last updated: March 2012
PDF icon Download PDF (164 KB)

Provider Directory - a list of network providers
PDF icon Download PDF (3.5 MB)

Evidence of Coverage - provides information about your benefits, membership, covered and non-covered services, member rights and responsibilities and other important plan details
PDF icon Download PDF (3.4 MB)

Summary of Benefits - provides a general summary of benefits and services for each of our plans
PDF icon Download PDF (455 KB)

Other Documents and Forms

Comprehensive Formulary - Peoples Health Choices Plus (HMO-POS), Peoples Health Choices Select (HMO-POS) and Peoples Health Secure Health (HMO SNP)
PDF file Download PDF (1.6 MB)

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

Step Therapy Criteria - describes step therapy criteria for select drugs on the Peoples Health formulary
PDF file 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.
PDF file 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
PDF file Download PDF (124 KB)

Appointment of Representative Form
PDF file Download PDF (66 KB)

Grievance or Complaint Form
PDF file Online Form

Mail-Order Prescription Drug Form
PDF icon Download PDF (267 KB)

Request for an Appeal or Redetermination Form

PDF file Online Form

Request for Medicare Prescription Drug Coverage Determination Form
PDF file Download PDF (28 KB)

Request for Redetermination of Medicare Prescription Drug Denial Form
PDF file Download PDF (90 KB)

Request for Medicare Prescription Drug Coverage Determination Form
PDF file Online Form


PDF icon Viewing PDF documents on your computer may require Adobe Acrobat Reader, which can be downloaded for free.

document viewer icon Viewing documents with our Document Viewer will require the Adobe Flash Player, which can be downloaded for free.

 

 

 


  • Home
  • Employment
  • Privacy Policy
  • Terms of Use
  • Licensure
  • Accreditation
  • Site Map

Questions about our plans?

Call toll-free at (800) 978-9765 to speak with a plan representative,
24 hours a day, seven days a week. TTY users may call 711.

Peoples Health plan members click here for Member Services contact information.

 

Compliment or complaint?

Call toll-free at (800) 222-8600 to speak with a Member Services representative,
8 a.m. to 8 p.m., seven days a week. TTY users may call 711. If you contact us on a weekend or holiday between February 15 and October 14, you may leave a message and we will return your call within one business day.

To file a complaint with Medicare click here.

 

 
 
 

Peoples Health Network is the administrator for Peoples Health, Inc.
Peoples Health is a Medicare Advantage organization with a Medicare contract.

H1961_PHWEB10012011_CMSApproved10202011
Last Update: January 01, 2012

You can follow Peoples Health
on the following sites:

YouTube icon
Flickr icon