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Member Plan Documents and Forms

View important 2020 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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2020 Plan Coverage Documents

Peoples Health Choices 65 #14 (HMO) | 2020

Plan Overview 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

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

Peoples Health Choices 65 #14 (HMO) for Northshore | 2020

Plan Overview for Peoples Health Choices 65 #14 for Northshore – An overview of plan benefits

Annual Notice of Changes for Peoples Health Choices 65 #14 for Northshore – 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 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 #14 for Northshore – A general summary of plan benefits

Peoples Health Choices Gold (HMO-POS) | 2020

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

Peoples Health Group Medicare (HMO-POS) | 2020

Plan Overview 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

Peoples Health Group Medicare (HMO-POS) for Office of Group Benefits (OGB) | 2020

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

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

Peoples Health Secure Choice #011 (HMO D-SNP) | 2020

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

Peoples Health Choices Value (HMO) | 2020

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

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

Other Important Documents, Links and Forms | 2020

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

2020 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.

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

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