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LIBRARY OF DOCUMENTS AND FORMS  
 

Here, you’ll find information and details about HAP Medicare Solutions along with special forms for mail order pharmacies, reimbursement of covered benefits and more.
If you have any questions, or if you’re unable to find what you’re looking for, please call us toll-free. We’ll be glad to assist you in any way we can.

QUICK LINKS

Information Brochures - HAP Medicare Solutions
Summary of Benefits - HAP Medicare Plans
Evidence of Coverage
Enrollment Forms - HAP Medicare Solutions
Provider Directory - HAP Senior Plus (hmo)-Henry Ford
Provider Directories - Alliance Medicare PPO or HAP Senior Plus (hmo-pos)-Expanded Network
Pharmacy Directory
Pharmacy Forms
Formulary Information
Formulary Determination Requests
Reimbursement Forms – Covered Medical Services and Prescription Drugs
Other Forms and Resources
Know Your Medical Rights
Medicare Plan Ratings (Star Ratings) - HAP Medicare Solutions

Medicare Plan Ratings (Star Ratings)
2012 Plan Rating HAP Senior Plus

2012 Plan Rating HAP Senior Plus Rx

2012 Plan Rating Alliance Medicare Rx (pdp)

2012 Plan Rating Alliance Medicare PPO

2012 Plan Rating Alliance Medicare PPO Rx

Informational Brochures – HAP Medicare Solutions
Alliance Medicare SupplementYou are now leaving HAP's Medicare-approved website

Alliance Medicare PPOYou are now leaving HAP's Medicare-approved website

Alliance Medicare Rx (pdp)You are now leaving HAP's Medicare-approved website

HAP Senior Plus (hmo-pos)-Expanded NetworkYou are now leaving HAP's Medicare-approved website

HAP Senior Plus (hmo)-Henry FordYou are now leaving HAP's Medicare-approved website

Summary of Benefits – HAP Medicare Plans
Alliance Medicare PPOYou are now leaving HAP's Medicare-approved website

Alliance Medicare Rx You are now leaving HAP's Medicare-approved website

HAP Senior Plus-Expanded NetworkYou are now leaving HAP's Medicare-approved website

HAP Senior Plus-Henry FordYou are now leaving HAP's Medicare-approved website

Evidence of Coverage – HAP Medicare Plans
Alliance Medicare PPO – Option 1You are now leaving HAP's Medicare-approved website

Alliance Medicare PPO – Option 2You are now leaving HAP's Medicare-approved website

Alliance Medicare Rx – Option 1You are now leaving HAP's Medicare-approved website

Alliance Medicare Rx – Option 2You are now leaving HAP's Medicare-approved website

HAP Senior Plus-Expanded Network – Option 1You are now leaving HAP's Medicare-approved website

HAP Senior Plus-Expanded Network – Option 2You are now leaving HAP's Medicare-approved website

HAP Senior Plus-Expanded Network – Option 3You are now leaving HAP's Medicare-approved website

HAP Senior Plus-Henry Ford – Option 1You are now leaving HAP's Medicare-approved website

HAP Senior Plus-Henry Ford – Option 2You are now leaving HAP's Medicare-approved website

HAP Senior Plus-Henry Ford – Option 3You are now leaving HAP's Medicare-approved website

Enrollment Forms – HAP Medicare Solutions

Alliance Medicare PPO – Enroll by Mail

Alliance Medicare Rx – Enroll by Mail

HAP Senior Plus-Expanded Network – Enroll by Mail

HAP Senior Plus-Henry Ford – Enroll by MailYou are now leaving HAP's Medicare-approved website

Application Form – Alliance Medicare SupplementYou are now leaving HAP's Medicare-approved website

Alliance Medicare Supplement – Plan and Premium Information
Choosing a Medigap PolicyYou are now leaving HAP's Medicare-approved website

Outline of Coverage – Alliance Medicare Supplement OutlineYou are now leaving HAP's Medicare-approved website

Premium Chart – Alliance Medicare SupplementYou are now leaving HAP's Medicare-approved website

Provider Directory
HAP Senior Plus (hmo)-Henry Ford

HAP Senior Plus (hmo)-Henry Ford Provider Directory

Provider Directories
Alliance Medicare PPO or HAP Senior Plus (hmo-pos)-Expanded Network

Wayne County Provider DirectoryYou are now leaving HAP's Medicare-approved website
Oakland County Provider DirectoryYou are now leaving HAP's Medicare-approved website
Macomb County Provider DirectoryYou are now leaving HAP's Medicare-approved website
Livingston, Monroe and Washtenaw Counties Provider DirectoryYou are now leaving HAP's Medicare-approved website
Genesee, Lapeer and St. Clair Counties Provider DirectoryYou are now leaving HAP's Medicare-approved website

Pharmacy DirectoryYou are now leaving HAP's Medicare-approved website
Pharmacy Directory – All CountiesYou are now leaving HAP's Medicare-approved website

Pharmacy Forms
Pharmacy Advantage Mail Order Form You are now leaving HAP's Medicare-approved website 

Walgreens Physician New Prescription Form - FaxYou are now leaving HAP's Medicare-approved website   Updated PDF!

Walgreens Mail Order Form – HAP Senior PlusYou are now leaving HAP's Medicare-approved website  Updated PDF! (Applicable for all 3 Part D Product lines). URL to be updated to walgreens_mail_partD.

Walgreens Mail Order Form – Alliance Medicare RxYou are now leaving HAP's Medicare-approved website Remove this URL. Only one URL is needed for order forms (See previous)

Walgreens Mail Order Form – Alliance Medicare PPO Remove this URL. Only one URL is needed for order forms (See previous)

Formulary Information
Comprehensive FormularyYou are now leaving HAP's Medicare-approved website

Formulary ChangesYou are now leaving HAP's Medicare-approved website Need Updated PDF!

Prior Authorization CriteriaYou are now leaving HAP's Medicare-approved website Need Updated PDF!

Quantity Limit Restriction ListYou are now leaving HAP's Medicare-approved website Need Updated PDF!

Step TherapyYou are now leaving HAP's Medicare-approved website Need Updated PDF!

 

Formulary Determination Requests
Determination Request for Medicare Prescription Drug CoverageYou are now leaving HAP's Medicare-approved website

Redetermination Request for Medicare Prescription Drug Coverage DenialYou are now leaving HAP's Medicare-approved website

Reimbursement Forms – Covered Medical Services and Prescription Drugs
Direct Member Reimbursement Form–Medical ServicesYou are now leaving HAP's Medicare-approved website
Direct Member Reimbursement Form–Part DYou are now leaving HAP's Medicare-approved website

Other Forms and Resources
Flexible Health Options FormYou are now leaving HAP's Medicare-approved website
(for HAP Senior Plus and Alliance Medicare PPO members only)
Submit a form for review and consideration of benefit payment.

Appointment of Representative FormYou are now leaving HAP's Medicare-approved website
Appoint a doctor, lawyer or family member to file a grievance, request a coverage determination, or file an appeal on your behalf.

Authorization for Disclosure of Protected Health Information FormYou are now leaving HAP's Medicare-approved website>
Appoint a doctor, lawyer or family member to file a Grievance on your behalf.

Know Your Medical Rights
Answers to your questions about electing a patient advocate.  (requires Adobe Reader You are now leaving HAP's Medicare-approved website).

 
 
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Alliance Medicare PPO

  • Eligible enrollees must have and keep Parts A and B to enroll in a Medicare Advantage Plan.
  • A beneficiary may only be enrolled in one Medicare Advantage plan at a time.
  • Enrollment in a Medicare Advantage plan is generally for the entire year.
  • Enrollees may leave a Medicare Advantage plan only at certain times of the year, or under certain special circumstances.
  • Alliance Medicare PPO eligible enrollees must have a permanent residence within the service area to enroll.
  • Enrollees may get care from contracted and non-contracted providers. Except for emergency and urgently needed care, enrollees will generally pay more when using non-contracted providers.
  • Submitting your application through the online process constitutes a valid enrollment election on your part. In the event of an omission on the form, you will be contacted by a Health Alliance Plan representative.
  • In response to your request for enrollment, you will receive a notice in the mail where we will acknowledge receipt of your completed request or deny your enrollment due to ineligibility per Medicare's regulations.


 
 
 
     
 

HAP Senior Plus (hmo)-Henry Ford

  • Eligible enrollees must have and keep Parts A and B to enroll in a Medicare Advantage Plan.
  • A beneficiary may only be enrolled in one Medicare Advantage plan at a time.
  • Enrollment in a Medicare Advantage plan is generally for the entire year.
  • Enrollees may leave a Medicare Advantage plan only at certain times of the year, or under certain special circumstances.
  • Medicare Advantage eligible enrollees must have a permanent residence within the service area to enroll.
  • HAP Senior Plus serves a specific service area. Eligible enrollees must have a permanent residence within the service area to enroll.
  • Because HAP Senior Plus is an HMO plan, enrollees must obtain all routine care from contracted providers within the network of their personal care physician.
  • Without authorization, neither HAP Senior Plus nor Medicare will pay for services received from non-contracted providers, except for emergency or urgently needed care or out of area renal dialysis.
  • Submitting your application through the online process constitutes a valid enrollment election on your part. In the event of an omission on the form, you will be contacted by a Health Alliance Plan representative.
  • In response to your request for enrollment, you will receive a notice in the mail where we will acknowledge receipt of your completed request or deny your enrollment due to ineligibility per Medicare's regulations.

 
 
 
     
 

HAP Senior Plus (hmo-pos)-Expanded Network

  • Eligible enrollees must have and keep Parts A and B to enroll in a Medicare Advantage Plan.
  • A beneficiary may only be enrolled in one Medicare Advantage plan at a time.
  • Enrollment in a Medicare Advantage plan is generally for the entire year.
  • Enrollees may leave a Medicare Advantage plan only at certain times of the year, or under certain special circumstances.
  • Medicare Advantage eligible enrollees must have a permanent residence within the service area to enroll.
  • HAP Senior Plus serves a specific service area. Eligible enrollees must have a permanent residence within the service area to enroll.
  • Because HAP Senior Plus is an HMO-POS plan, enrollees must obtain all routine care not available under the Point-of-Service benefit from contracted providers within the plan's network.
  • Without authorization, neither HAP Senior Plus nor Medicare will pay for services received from non-contracted providers, except for emergency or urgently needed care or out of area renal dialysis.
  • Submitting your application through the online process constitutes a valid enrollment election on your part. In the event of an omission on the form, you will be contacted by a Health Alliance Plan representative.
  • In response to your request for enrollment, you will receive a notice in the mail where we will acknowledge receipt of your completed request or deny your enrollment due to ineligibility per Medicare's regulations.

 
 
 
     
 

Alliance Medicare Rx (pdp)

  • Eligible enrollees must have Part A or Part B to enroll in a Prescription Drug Plan.
  • Enrollees must continue to pay the Part B premium unless otherwise paid for under Medicaid or by another third party.
  • A beneficiary may only be enrolled in one Prescription Drug Plan at a time.
  • Enrollment in a Prescription Drug Plan is generally for the entire year.
  • Enrollees may leave a Prescription Drug Plan only at certain times of the year, or under certain special circumstances.
  • Alliance Medicare Rx eligible enrollees must have a permanent residence within the service area to enroll.
  • Submitting your application through the online process constitutes a valid enrollment election on your part. In the event of an omission on the form, you will be contacted by a Health Alliance Plan representative.
  • In response to your request for enrollment, you will receive a notice in the mail where we will acknowledge receipt of your completed request or deny your enrollment due to ineligibility per Medicare's regulations.