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Member Plan Documents and Forms | 2022

View important 2022 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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2022 Plan Coverage Documents

Peoples Health Choices 65 (HMO) Greater New Orleans and Baton Rouge Area | 2022

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

For members with permanent residence in East Baton Rouge, Jefferson or Orleans parish:
Annual Notice of Changes for Peoples Health Choices 65 Greater New Orleans and Baton Rouge Area – A summary of plan benefit changes compared to the previous year and other important plan details

For members with permanent residence in Ascension, East Feliciana, Iberville, Livingston, St. Charles, St. Helena or West Baton Rouge parish:
Annual Notice of Changes for Peoples Health Choice 65 Rural Southeast to Greater New Orleans and Baton Rouge Area – A summary of plan benefit changes compared to the previous year and other important plan details

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

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

2022 Medicare Star Ratings Summary (Coming Soon)

Peoples Health Choices 65 (HMO) Northshore | 2022

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

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

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

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

2022 Medicare Star Ratings Summary (Coming Soon)

Peoples Health Choices 65 (HMO) Southland | 2022

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

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

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

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

2022 Medicare Star Ratings Summary (Coming Soon)

Peoples Health Choices 65 (HMO) Rural Southeast | 2022

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

For members with permanent residence in Plaquemines, Pointe Coupee, St. Bernard, St. James, St. John the Baptist or West Feliciana parish:
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

For members with permanent residence in Ascension, East Feliciana, Iberville, Livingston, St. Charles, St. Helena or West Baton Rouge parish:
Annual Notice of Changes for Peoples Health Choice 65 Rural Southeast to Greater New Orleans and Baton Rouge Area – A summary of plan benefit changes compared to the previous year and other important plan details

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

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

2022 Medicare Star Ratings Summary (Coming Soon)

Peoples Health Choices Gold (HMO) | 2022

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

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 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

2022 Medicare Star Ratings Summary (Coming Soon)

Peoples Health Choices (PPO) | 2022

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

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

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

2022 Star Ratings Summary (Coming Soon)

Peoples Health Patriot (PPO) | 2022

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

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

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

2022 Star Ratings Summary (Coming Soon)

Peoples Health Group Medicare (HMO-POS) | 2022

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

2022 Star Ratings Summary (Coming Soon)

Peoples Health Group Medicare (HMO-POS) Office of Group Benefits (OGB) | 2022

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

Annual Notice of Changes for Peoples Health Group Medicare 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 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

2022 Star Ratings Summary (Coming Soon)

Peoples Health Secure Choice (HMO D-SNP) | 2022

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

2022 Star Ratings Summary (Coming Soon)

Peoples Health Secure Complete (HMO D-SNP) | 2022

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

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

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

2022 Star Ratings Summary (Coming Soon)

Other Important Documents, Links and Forms | 2022

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

2022 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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