Prior to downloading your form, please note the following:
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be able to see the purpose and requirements of the document. Please take
time to read these requirements to check if they are applicable to you.
Some of the documents presented here may not apply to you depending on
your situation.
- Some forms may be available for electronic filing.
- The forms below are not in alphabetical order, please look carefully for the form you require.
- When a form is due to expire, the form and any changes must be reviewed by the
management. If a form expires while it is being reviewed, the form may still be used. Once a new edition is available, the website will be updated to ensure
only useable editions are listed.
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Miscellaneous
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Form Name
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Description
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Edition Info
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Download
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Access Request Form
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Access Request Form
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1/1/2011
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download
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Accounting Request Form
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Accounting Request Form
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1/1/2011
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download
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Advance Directives
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Advance Directives Form
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1/1/2011
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download
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Amendment Request Form
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Amendment Request Form
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09/09/2011
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download
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Fraud, Waste and Abuse
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PTHP Fraud, Waste and Abuse
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download
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How to Appoint a Representative
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If a beneficiary would like to appoint a person to file a grievance, request a coverage determination or exception, or request an appeal on his or her behalf, the beneficiary and the person accepting the appointment must fill out this form (or a written equivalent) and submit it with the request.
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12/10/2010
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download
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Notice of Privacy Practices
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Coverage Determination Form
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08/16/2011
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download
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Plan Overview 2012
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Plan Overview 2012
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09/22/2011
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download
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Provider Directory 2012
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Provider Directory 2012
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09/20/2011
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download
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Release of Information Form
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PTHP-Release of Information Form
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08/18/2011
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download
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Restriction Request Form
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Restriction Request Form
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1/1/2011
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download
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| Back To Top |
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Newsletters
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Form Name
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Description
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Edition Info
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Download
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PTHP Newsletter Fall 2011
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Fall 2011 Newsletter
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09/15/2011
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download
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| Back To Top |
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Quality
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Form Name
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Description
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Edition Info
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Download
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Access to Care
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Access to Care – PTHP Results
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1/1/2011
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download
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Cancer Screening
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Cancer Screening
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1/1/2011
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download
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Cardiac Care
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Cardiac Care
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download
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Customer Service
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Customer Service
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1/1/2011
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download
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Diabetes Care
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Diabetes Care
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1/1/2011
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download
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Getting Care Quickly
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Getting Care Quickly
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1/1/2011
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download
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Getting Needed Care
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Getting Needed Care
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1/1/2011
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download
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How Well Doctors Communicate
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How Well Doctors Communicate
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1/1/2011
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download
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Other Types of Care
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Other Types of Care
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1/1/2011
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download
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Quality Improvement Program Evaluation
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Evaluation of Primetime Health Plan's quality improvement program for 2009.
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3/10/2010
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download
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| Back To Top |
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Evidence of Coverage
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Form Name
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Description
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Edition Info
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Download
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Basic MA Evidence of Coverage 2012
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Basic MA Evidence of Coverage 2012
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download
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Basic Select Evidence of Coverage 2012
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Basic MA Evidence of Coverage 2012
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download
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Plus Evidence of Coverage 2012
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Plus Evidence of Coverage 2012
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download
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Premier Evidence of Coverage 2012
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Premier Evidence of Coverage 2012
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download
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Prime PPO Evidence of Coverage 2012
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Prime PPO Evidence of Coverage 2012
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download
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| Back To Top |
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Service Area Maps
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Form Name
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Description
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Edition Info
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Download
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HMO or PPO County Map
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Coverage Areas/Counties for HMO or PPO PLAN Options
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12/17/2009
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download
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| Back To Top |
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Prescription Drug Information (Part D)
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Form Name
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Description
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Edition Info
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Download
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2012 LIS Premium Summary
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2012 LIS Premium Summary
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download
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Comprehensive Formulary 2012
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Comprehensive Formulary 2012
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09/28/2011
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download
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Formulary 2011
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The formulary document contains information on how it may be changed during the year.
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09/09/2011
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download
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Formulary 2012
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The formulary document contains information on how it may be changed during the year.
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download
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Medical Care, Services, and Payment
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Medical Care, Services, and Payment
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1/1/2011
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download
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Part D Prescription Drugs
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Part D Prescription Drugs
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1/1/2011
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download
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Pharmacy Directory 2012
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Pharmacy Directory 2012
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09/23/2011
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download
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Physician and Hospital Validation
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Physician and Hospital Validation
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1/1/2011
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download
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Prior Authorization B vs D
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Criteria and List of Drugs Requiring Prior Authorization B vs. D
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10/01/2011
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download
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Quality Assurance Policies and Procedures
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Includes medication therapy management and drug utilization programs to prevent over
and under utilization of prescribed medications to ensure measurements for medication
error, reduction of drug interactions and promote member safety.
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11/12/2005
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download
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Request for Redetermination MAPD
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Request for Redetermination MAPD
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12/5/2011
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download
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Transition Policy
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04/15/2010
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download
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| Back To Top |
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Provider Forms
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Form Name
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Description
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Edition Info
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Download
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Prior Authorizations
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Pharmaceutical Prior Authorizations List
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1/1/2011
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download
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| Back To Top |
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Summary of Benefits
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Form Name
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Description
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Edition Info
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Download
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Basic MA Only Summary of Benefits 2012
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Basic MA Only Summary of Benefits 2012
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download
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Basic Select Summary of Benefits 2012
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Basic Select Summary of Benefits 2012
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09/22/2011
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download
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Plus Summary of Benefits 2012
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Plus Summary of Benefits 2012
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download
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Premier Summary of Benefits 2012
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Premier Summary of Benefits 2012
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download
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Prime PPO Summary of Benefits 2012
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Prime PPO Summary of Benefits 2012
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09/22/2011
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download
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| Back To Top |
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Enrollment
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Form Name
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Description
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Edition Info
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Download
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2012 Enrollment Checklist
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2012 Enrollment Checklist
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09/22/2011
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download
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2012 Enrollment Form Addendum
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2012 Enrollment Form Addendum
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download
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2012 HMO Enrollment Form
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2012 HMO Enrollment Form
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09/22/2011
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download
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2012 PPO Enrollment Form
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2012 PPO Enrollment Form
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09/22/2011
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download
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Electronic Funds Transfer Form (EFT Form)
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You may choose to have your monthly premium payment automatically deducted from a checking account. Please complete this form only if you are choosing to have your premium deducted from your bank checking account (EFT option).
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1/1/2011
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download
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Enrollment Form Addendum
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Attestation of Enrollment Eligibility form, certifying that, to the best of your knowledge, you are eligible for an Enrollment Period.
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1/1/2011
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download
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Optional Supplemental Benefits Enrollment Form
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Optional Supplemental Benefits Enrollment Form
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09/22/2011
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download
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| Back To Top |
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Plan Ratings
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Form Name
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Description
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Edition Info
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Download
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HMO Plan Ratings
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HMO Plan Ratings
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10/1/2011
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download
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PPO Plan Ratings
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PPO Plan Ratings
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10/1/2011
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download
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| Back To Top |
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Annual Notice of Change Documents
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Form Name
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Description
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Edition Info
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Download
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Annual Notice of Change - Basic MA 2012
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Annual Notice of Change - Basic MA 2012
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download
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Annual Notice of Change - Basic Select 2012
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Annual Notice of Change - Basic Select 2012
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download
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Annual Notice of Change - Plus 2012
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Annual Notice of Change - Plus 2012
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09/20/2011
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download
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Annual Notice of Change - Premier 2012
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Annual Notice of Change - Premier 2012
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download
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Annual Notice of Change - Prime 2012
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Annual Notice of Change - Prime 2012
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download
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| Back To Top |