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
Download PDF (2 MB)

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

Provider Directory - a list of network providers
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
Download PDF (3.4 MB)

Summary of Benefits - provides a general summary of benefits and services for each of our plans
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)
Download PDF (1.6 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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