HAP

Forms

Here you’ll find links to pharmacy directories, special forms for mail order pharmacies and reimbursement of covered benefits and more. If you have any questions, or if you’re unable to find what you’re looking for, please contact us
We’ll be glad to assist you in any way we can.

Please note, all of these documents require Adobe Reader to download. Download Adobe Reader for free. (You are leaving a Medicare-approved site)

Summary of Benefits – 2017 HAP Medicare Plans

HAP Senior Plus (HMO) plans
HAP Senior Plus (HMO-POS) plans
HAP Senior Plus (PPO) plans

Evidence of Coverage – 2017 HAP Medicare Plans

HAP Senior Plus Tiered Access (HMO) - Option 2
HAP Senior Plus (HMO) - Option 0
HAP Senior Plus Medical Only (HMO) - Option 1
HAP Senior Plus (HMO-POS) – Option 1
HAP Senior Plus (HMO-POS) – Option 2
HAP Senior Plus (HMO-POS) – Option 3
HAP Senior Plus (PPO) – Option 1
HAP Senior Plus (PPO) – Option 2

Annual Notice of Changes – 2017 HAP Medicare Plans

HAP Senior Plus Tiered Access (HMO) – Option 2
HAP Senior Plus (HMO) – Option 0
HAP Senior Plus Medical Only (HMO) – Option 1
HAP Senior Plus (HMO-POS) – Option 1
HAP Senior Plus (HMO-POS) – Option 2
HAP Senior Plus (HMO-POS) - Option 3
HAP Senior Plus (PPO) – Option 1
HAP Senior Plus (PPO) – Option 2

The Summary of Benefits, Evidence of Coverage and Annual Notice of Changes documents included above are for HAP individual Medicare plan members only. If you receive coverage through a group or employer, please contact us for more information.

Pharmacy Forms

Pharmacy Advantage Mail Order Form
Walgreens Physician New Prescription Form – Fax
Walgreens Mail Order Form – HAP Senior Plus

Formulary Information

2017 Comprehensive Formulary
Prior Authorization Criteria
Quantity Limit Restriction List
Step Therapy Criteria
Part B vs, Part D Criteria

Formulary Determination Requests

Determination Request for Medicare Prescription Drug Coverage
Redetermination Request for Medicare Prescription Drug Coverage Denial

Reimbursement Forms – Covered Medical Services and Prescription Drugs

Direct Pharmacy Reimbursement Form
Direct Reimbursement Form – Medical Claim

Other Forms and Resources

Flexible Health Options Form - (for HAP Senior Plus members only) Submit a form for review and consideration of benefit payment.
Appointment of Representative Form - Appoint a doctor, lawyer or family member to file a grievance, request a coverage determination or file an appeal on your behalf.
Know Your Medical Rights - Understand your right to appoint a representative to act on your behalf.
Authorization for Disclosure of Protected Health Information Form - Appoint a doctor, lawyer or family member to file a grievance on your behalf.
Release Form
Provider Waiver of Liability - (for HAP Senior Plus members only) A noncontract physician or other noncontract provider who has furnished a service to the enrollee can formally agree to waive any right to payment from the enrollee for that service.

Have questions?

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