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
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
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
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
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
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
Peoples Health Patriot (PPO) | 2022
Plan Overview for Peoples Health Patriot – An overview of plan benefits
Annual Notice of Changes for Peoples Health Patriot – A 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
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
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
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
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 Complete – A 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
Peoples Health Secure Health (HMO D-SNP) | 2022
Plan Overview 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
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
Vendor Information – A listing of providers offering benefit-related services for your plan
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
Prescription Drug Reimbursement Form – For requesting reimbursement for covered medications purchased at retail cost
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
Notice of Privacy Practices – Description of how your medical information may be used and disclosed and how you can get access to this information