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Access important 2017 plan documents and forms on this page.

If you are a plan member and would like any of the following documents mailed to you, please call member services at 504-849-4685225-346-5704 or toll-free 1-800-222-8600, seven days a week, from 7 a.m. to 9 p.m. TTY users may call 711. If you contact us on a weekend or holiday, you may need to leave a message, but we will return your call within one business day. You should receive the document within two weeks of your request.

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Plan Coverage and Provider Network Documents

Peoples Health Choices 65 #14 (HMO)

Quick Guide for Peoples Health Choices 65 #14 – An overview of plan benefits

Annual Notice of Changes for Peoples Health Choices 65 #14 – A summary of plan benefit changes compared to the previous year and other important plan details

Annual Notice of Changes for Peoples Health Choices Plus (HMO) – A summary of plan benefit changes compared to the previous year and other important plan details

Evidence of Coverage for Peoples Health Choices 65 #14 – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details

Summary of Benefits for Peoples Health Choices 65 #14– A general summary of plan benefits

Abridged Formulary – A partial list of covered drugs

Abridged Formulary addendum – A listing of changes to the Abridged Formulary (last updated February 2017)

Provider Directory – A searchable online listing of network providers and pharmacies

Peoples Health Choices 65 #14 (HMO) for St. Tammany Parish

Quick Guide for Peoples Health Choices 65 #14 for St. Tammany Parish – An overview of plan benefits

Annual Notice of Changes for Peoples Health Choices 65 #14 for St. Tammany Parish– A summary of plan benefit changes compared to the previous year and other important plan details

Evidence of Coverage for Peoples Health Choices 65 #14 for St. Tammany Parish – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details

Summary of Benefits for Peoples Health Choices 65 #14 for St. Tammany Parish – A general summary of plan benefits

Abridged Formulary – A partial list of covered drugs

Abridged Formulary addendum – A listing of changes to the Abridged Formulary (last updated February 2017)

Provider Directory – A searchable online listing of network providers and pharmacies

Peoples Health Choices Gold (HMO)

Quick Guide for Peoples Health Choices Gold – An overview of plan benefits

Evidence of Coverage for Peoples Health Choices Gold – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details

Summary of Benefits for Peoples Health Choices Gold – A general summary of plan benefits

Abridged Formulary – A partial list of covered drugs

Abridged Formulary addendum – A listing of changes to the Abridged Formulary (last updated February 2017)

Provider Directory – A searchable online listing of network providers and pharmacies

Peoples Health Choices Platinum #009 (HMO)

Quick Guide for Peoples Health Choices Platinum #009 – An overview of plan benefits

Annual Notice of Changes for Peoples Health Choices Platinum #009 – A summary of plan benefit changes compared to the previous year and other important plan details

Evidence of Coverage for Peoples Health Choices Platinum #009 – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details

Summary of Benefits for Peoples Health Choices Platinum #009 – A general summary of plan benefits

Abridged Formulary – A partial list of covered drugs

Abridged Formulary addendum – A listing of changes to the Abridged Formulary (last updated February 2017)

Provider Directory – A searchable online listing of network providers and pharmacies

Peoples Health Choices Premium (HMO)

Quick Guide for Peoples Health Choices Premium – An overview of plan benefits

Evidence of Coverage for Peoples Health Choices Premium – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details

Summary of Benefits for Peoples Health Choices Premium– A general summary of plan benefits

Abridged Formulary – A partial list of covered drugs

Abridged Formulary addendum – A listing of changes to the Abridged Formulary (last updated February 2017)

Provider Directory – A searchable online listing of network providers and pharmacies

Peoples Health Choices Select (HMO)

Quick Guide for Peoples Health Choices Select – An overview of plan benefits

Annual Notice of Changes for Peoples Health Choices Select – A summary of plan benefit changes compared to the previous year and other important plan details

Evidence of Coverage for Peoples Health Choices Select– Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details

Summary of Benefits for Peoples Health Choices Select– A general summary of plan benefits

Abridged Formulary – A partial list of covered drugs

Abridged Formulary addendum – A listing of changes to the Abridged Formulary (last updated February 2017)

Provider Directory – A searchable online listing of network providers and pharmacies

Peoples Health Group Medicare (HMO-POS)

Quick Guide for Peoples Health Group Medicare – An overview of plan benefits

Annual Notice of Changes for Peoples Health Group Medicare – A summary of plan benefit changes compared to the previous year and other important plan details

Evidence of Coverage for Peoples Health Group Medicare – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details

Abridged Formulary – A partial list of covered drugs

Abridged Formulary addendum – A listing of changes to the Abridged Formulary (last updated February 2017)

Provider Directory – A searchable online listing of network providers and pharmacies

Peoples Health Group Medicare (HMO-POS) for Office of Group Benefits

Quick Guide for Peoples Health Group Medicare for Office of Group Benefits – An overview of plan benefits

Annual Notice of Changes for Peoples Health Group Medicare for Office of Group Benefits – A summary of plan benefit changes compared to the previous year and other important plan details

Evidence of Coverage for Peoples Health Group Medicare for Office of Group Benefits – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details

Abridged Formulary – A partial list of covered drugs

Abridged Formulary addendum – A listing of changes to the Abridged Formulary (last updated February 2017)

Provider Directory – A searchable online listing of network providers and pharmacies

Peoples Health Secure Choice #011 (HMO SNP)

Annual Notice of Changes for Peoples Health Secure Choice #011 – A summary of plan benefit changes compared to the previous year and other important plan details

Evidence of Coverage for Peoples Health Secure Choice #011 – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details

Summary of Benefits for Peoples Health Secure Choice #011 – A general summary of plan benefits

Abridged Formulary – A partial list of covered drugs

Abridged Formulary addendum – A listing of changes to the Abridged Formulary (last updated February 2017)

Provider Directory – A searchable online listing of network providers and pharmacies

Peoples Health Secure Health (HMO SNP)

Quick Guide for Peoples Health Secure Health – An overview of plan benefits

Annual Notice of Changes for Peoples Health Secure Health – A summary of plan benefit changes compared to the previous year and other important plan details

Annual Notice of Changes for Peoples Health Secure Choice #010 (HMO SNP) – A summary of plan benefit changes compared to the previous year and other important plan details

Evidence of Coverage for Peoples Health Secure Health – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details

Summary of Benefits for Peoples Health Secure Health – A general summary of plan benefits

Abridged Formulary – A partial list of covered drugs

Abridged Formulary addendum – A listing of changes to the Abridged Formulary (last updated February 2017)

Provider Directory – A searchable online listing of network providers and pharmacies

Important Documents, Links and Forms

Medicare Health Plans Overview Brochure

Medicare Health Plans Overview Brochure – A description of benefits and services offered by Peoples Health plans

Coverage Decisions, Appeals and Grievances

Appointment of Representative Form – To designate someone the right to act on your behalf as your representative for requesting a coverage decision or an appeal or making a grievance (complaint)

Request for Medicare Prescription Drug Coverage Determination Form – To request a decision on coverage of a prescription drug; you also have the option to request a coverage determination by completing a form through the Medicare website

Request for an Appeal Form – An online form to request an appeal for coverage of medical services or a prescription drug

Request for Redetermination of Medicare Prescription Drug Denial Form – to request reconsideration of our decision on how we will cover or pay for a prescription drug

Grievance or Complaint Form
 – An online form to make a complaint (grievance)

Prescription Drugs

2017 Comprehensive Formulary – A complete list of covered drugs

2017 Prior Authorization Criteria
 – Detailed criteria for select covered drugs

2017 Step Therapy Criteria
 – Detailed criteria for select covered drugs

Mail-Order Prescription Drug Form – For ordering eligible prescription drugs through the Peoples Health network mail-order pharmacy, CVS Caremark

Privacy

Department of Veterans Affairs Request for and Authorization to Release Medical Records – A form for requesting the release of your medical records or information from the Department of Veterans Affairs to Peoples Health

Notice of Privacy Practices
 – Description of how your medical information may be used and disclosed and how you can get access to this information