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Member Plan Documents and Forms | 2021

Looking for 2020 plan documents? Click here.

View important 2021 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 toll-free at 1-800-222-8600, seven days a week, from 8 a.m. to 8 p.m. TTY users may call 711. If you contact us on a weekend or holiday, we will reach out to you within one business day. You should receive the document within two weeks of your request.

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2021 Plan Coverage Documents

Peoples Health Choices 65 (HMO) Orleans, Jefferson, East Baton Rouge | 2021

Plan Overview for Peoples Health Choices 65 Orleans, Jefferson, East Baton Rouge – An overview of plan benefits

Annual Notice of Changes for Peoples Health Choices 65 Orleans, Jefferson, East Baton Rouge – A summary of plan benefit changes compared to the previous year and other important plan details

Evidence of Coverage for Peoples Health Choices 65 Orleans, Jefferson, East Baton Rouge – 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 Orleans, Jefferson, East Baton Rouge – A general summary of plan benefits

Vendor Information – A listing of providers offering benefit-related services for your plan

2021 Medicare Star Ratings Summary

Peoples Health Choices 65 (HMO) Northshore | 2021

Plan Overview for Peoples Health Choices 65 Northshore – An overview of plan benefits

Annual Notice of Changes for Peoples Health Choices 65 Northshore – A summary of plan benefit changes compared to the previ ous year and other important plan details

Evidence of Coverage for Peoples Health Choices 65 Northshore – 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 Northshore – A general summary of plan benefits

Vendor Information – A listing of providers offering benefit-related services for your plan

2021 Medicare Star Ratings Summary

Peoples Health Choices 65 (HMO) Southland | 2021

Plan Overview for Peoples Health Choices 65 Southland – An overview of plan benefits

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

Evidence of Coverage for Peoples Health Choices 65 Southland – 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 Southland – A general summary of plan benefits

Vendor Information – A listing of providers offering benefit-related services for your plan

2021 Medicare Star Ratings Summary

Peoples Health Choices 65 (HMO) Rural Southeast | 2021

Plan Overview for Peoples Health Choices 65 Rural Southeast – An overview of plan benefits

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

Evidence of Coverage for Peoples Health Choices 65 Rural Southeast – 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 Rural Southeast – A general summary of plan benefits

Vendor Information – A listing of providers offering benefit-related services for your plan

2021 Medicare Star Ratings Summary

Peoples Health Choices Gold (HMO) | 2021

Plan Overview for Peoples Health Choices Gold – An overview of plan benefits

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

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

Vendor Information – A listing of providers offering benefit-related services for your plan

2021 Medicare Star Ratings Summary

Peoples Health Choices Value (HMO) | 2021

Plan Overview for Peoples Health Choices Value – An overview of plan benefits

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

Evidence of Coverage for Peoples Health Choices Value – 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 Value – A general summary of plan benefits

Vendor Information – A listing of providers offering benefit-related services for your plan

2021 Medicare Star Ratings Summary

Peoples Health Choices (PPO) | 2021

Plan Overview for Peoples Health Choices  – An overview of plan benefits

Evidence of Coverage for Peoples Health Choices – 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 – A general summary of plan benefits

Vendor Information – A listing of providers offering benefit-related services for your plan

2021 Star Ratings Summary

Peoples Health Patriot (PPO) | 2021

Plan Overview for Peoples Health Patriot – An overview of plan benefits

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

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

Vendor Information – A listing of providers offering benefit-related services for your plan

2021 Star Ratings Summary

Peoples Health Group Medicare (HMO-POS) | 2021

Plan Overview for Peoples Health Group Medicare – An overview of plan benefits

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

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

Vendor Information – A listing of providers offering benefit-related services for your plan

2021 Star Ratings Summary

Peoples Health Group Medicare (HMO-POS) for Office of Group Benefits (OGB) | 2021

Plan Overview for Peoples Health Group Medicare for Office of Group Benefits (OGB) – An overview of plan benefits

Annual Notice of Changes for Peoples Health Group Medicare for Office of Group Benefits (OGB) – 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 (OGB) – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details

Vendor Information – A listing of providers offering benefit-related services for your plan

2021 Star Ratings Summary

Peoples Health Secure Choice (HMO D-SNP) | 2021

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

Evidence of Coverage for Peoples Health Secure Choice – 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 – A general summary of plan benefits

Vendor Information – A listing of providers offering benefit-related services for your plan

2021 Star Ratings Summary

Peoples Health Secure Complete (HMO D-SNP) | 2021

Plan Overview for Peoples Health Secure Complete – An overview of plan benefits

Evidence of Coverage for Peoples Health Secure Complete – 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 Complete – A general summary of plan benefits

Vendor Information – A listing of providers offering benefit-related services for your plan

2021 Star Ratings Summary

Other Important Documents, Links and Forms | 2021

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)

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

Medicare Part D Coverage Determination Request Form (for use by members and providers) – For requesting a decision on coverage of a prescription drug

Printable Form [Updated 3/07/2019]

You may also file a standard prescription drug coverage determination online by creating or signing in to your account at www.optumrx.com.

Request for Redetermination – For requesting a review of our coverage decision for a prescription drug

Printable Form

Online Form

Prescription Drug Reimbursement Form – For requesting reimbursement for covered medications purchased at retail cost

Printable Form

Online Form

Prescription Drugs

2021 Medication Search – Search medications online

Prior Authorization Criteria– Detailed criteria for select covered drugs

Step Therapy Criteria – Detailed criteria for select covered drugs

Mail-Order Prescription Drug Form – For ordering eligible prescription drugs through our network mail-order pharmacy

Privacy

Authorization for Release of Protected Health Information – A form for giving Peoples Health permission to release specific protected health information about you to a defined party for a designated purpose and for a set period of time. Note: There is a different form for authorizing another person to make decisions or submit requests (such as account changes, complaints and requests for coverage) for you or on your behalf. Use the Limited Healthcare Power of Attorney form for that purpose.

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

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