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Important forms and documents

Here you’ll find forms relating to your Medicare plan. If you have any questions, or if you’re unable to find what you’re looking for, contact us.

Please choose the type of form you need from the following list. Please note, the Summary of Benefits, Evidence of Coverage and Annual Notice of Changes documents included below are for HAP individual Medicare plan members only. If you receive coverage through a group or employer, please contact us for more information.

Summary of Benefits

2023 HAP Medicare Plans

HAP Medicare Advantage (HMO) plans

HAP MSU Health Care Medicare (HMO) plan

HAP Senior Plus (HMO-POS) plans

HAP Senior Plus (PPO) Plans

HAP Choice Medicare - West Michigan (HMO) plans

HAP Medicare Complete Duals (HMO D-SNP) plans
Evidence of Coverage

2023 HAP Medicare plans

HAP Senior Plus Henry Ford Tiered Access (HMO)

HAP Senior Plus (HMO)

HAP Senior Plus Medical Only (HMO)

HAP Primary Choice Medicare (HMO)

HAP Choice Medicare - West Michigan (HMO) - Option 1

HAP Choice Medicare - West Michigan (HMO) - Option 2

HAP Senior Plus (HMO-POS) - Option 1

HAP Senior Plus (HMO-POS) - Option 2

HAP Senior Plus (PPO) - Option 1

HAP Senior Plus (PPO) - Option 2

HAP Senior Plus (PPO) - Option 3

HAP Senior Plus (PPO) - Option 4

HAP Medicare Flex (PPO)

HAP Medicare Complete Duals (HMO D-SNP)

HAP MSUHC Medicare (HMO)
Annual Notice of Changes

2023 HAP Medicare plans

HAP Senior Plus Henry Ford Tiered Access (HMO)

HAP Senior Plus (HMO)

HAP Senior Plus Medical Only (HMO)

HAP Primary Choice Medicare (HMO)

HAP Choice Medicare - West Michigan (HMO) - Option 1

HAP Choice Medicare - West Michigan (HMO) - Option 2

HAP Senior Plus (HMO-POS) - Option 1

HAP Senior Plus (HMO-POS) - Option 2

HAP Senior Plus (PPO) - Option 1

HAP Senior Plus (PPO) - Option 2

HAP Senior Plus (PPO) - Option 3

HAP Senior Plus (PPO) - Option 4

HAP Medicare Complete Duals (HMO D-SNP)
Pharmacy forms

Pharmacy Advantage Enrollment Form
Drug formulary information

2023

2023 HAP Drug Formulary

2023 Prior Authorization Criteria

2023 Step Therapy 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

Reimbursement Form for Health Care Services Provided Outside the U.S.
Authorization for automatic withdrawal

Authorization for Automatic Withdrawal

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Other forms and resources

Appointment of Representative Form

Know Your Medical Rights (Advanced Directive)

Authorization for HAP to Release Personal Health Information

Admission Team Authorization Request

Outpatient Medical Authorization Request Form

Manage your Medicare benefits and view personalized plan information

Health Alliance Plan (HAP) has HMO, HMO-POS, PPO plans with Medicare contracts. HAP Medicare Complete Duals (HMO D-SNP) is a Medicare health plan with a Medicare contract and a contract with the Michigan Medicaid Program. Enrollment depends on contract renewals.

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Important forms and documents

2023 HAP Medicare Plans

2023 HAP Medicare plans

2023 HAP Medicare plans

2023

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