Documents and Forms (2012)

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The following documents provide detailed information on Peoples Health Group Medicare (HMO-POS) plan benefits and plan information.

There are two different types of group Medicare plans offered by Peoples Health. One is a standard plan for employer groups. This plan is called Peoples Health Group Medicare Gold (HMO-POS). The other is a customized plan created for retirees with the Louisiana Office of Group Benefits (OGB); this plan is called Peoples Health Group Medicare for OGB (HMO-POS).

The plan documents for both of these plans are listed below.

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.

Peoples Health Group Medicare (HMO-POS)

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

Abridged Formulary - a partial list of the open formulary for prescription drugs
Download PDF (1.5 MB)
Addendum—last updated: March 2012
Download PDF (160 KB)

Provider Directory - a listing of network providers
Download PDF (3.6 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)

Peoples Health Group Medicare for OGB (HMO-POS)

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

Abridged Formulary - a partial list of the open formulary for prescription drugs
Download PDF (1.5 MB)
Addendum—last updated: March 2012
Download PDF (160 KB)

Provider Directory - a listing of network providers
Download PDF (3.6 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)

Other Documents and Forms

Comprehensive Formulary - Peoples Health Group Medicare (HMO-POS)
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
Online Form

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

Pharmacy Request Form
Download PDF (124 KB)

Request for an Appeal or Redetermination
Online Form

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

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

Request for Standard Medicare Prescription Drug Coverage Determination Form
Online Form

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