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Forms

Following are links to commonly used forms for our Medicare Advantage and prescription drug plans (requires Adobe Reader).

Appointment of Representative Form
Appoint a doctor, lawyer or family member to file a Coverage Determination request 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.

Coverage Determination Request Form (for Enrollees)
Request a drug coverage rule exception.

Direct Member Reimbursement Form
Request reimbursement for out-of-pocket payment of covered drugs

Medicare Part D Coverage Determination Request Form (for Providers)
Request prior authorization for a formulary drug, a formulary exception or a tiering exception.

Medication Request Form
Request prior authorization for a formulary drug, a formulary exception (coverage for a non-formulary drug) or a tiering exception.

Plan Enrollment Form*

  • HAP Senior Plus through Michigan Public School Employees Retirement System

    Completed forms must be mailed directly to:

    Office of Retirement Services
    P.O. Box 30171
    Lansing, MI 48909-7671

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