Documents and Forms
Find a Plan Infographic (PDF 89KB); Large print version (PDF 63KB); Spanish version (PDF 77KB)
Multi-language Interpreter Services
General Forms
- If you are not enrolled in the Health Options Program: Application Form (PDF 578KB)
- If you are enrolled in the Health Options Program and looking to change your coverage: Change Form (PDF 607KB)
- CMS Appointment of Representative Form (Form CMS-1696) (PDF 76KB)
- Health Options Program Major Medical Claim Form (PDF 280K)
- Health Options Program (MetLife) Dental Claim Form (PDF 675K)
- Submit EyeMed (vision) claims through the online claim form or by logging in to the member area of the EyeMed website.
- Health Options Program (OptumRx) Prescription Drug Claim Form (PDF 457K)
- Health Options Program (OptumRx) Prescription Drug Prior Authorization Form (PDF 310K)
- Health Options Program (OptumRx) Prescription Drug Mail Service Pharmacy Order Form (PDF 496K)
- CMS Appointment of Representative Form (Form CMS-1696) (PDF 76K)
Medicare-Eligible
2025 Medicare Star Rating (in Spanish)
- Enrollment Guide for Medicare-Eligible Members (PDF 2.7MB); Large print version (PDF 3.2MB); Spanish version (PDF 2.8MB)
- 2024 HOP Medical Plan Summary Plan Description (SPD) (PDF 625KB)
- 2024 Value Medical Plan Summary Plan Description (SPD) (PDF 372KB)
- Medicare.gov online supplier directory: Search for providers that cover Medicare Part B-eligible durable medical equipment, prostheses, orthotics, and supplies.
- Medicare Advantage Plan Guide: Southwest Pennsylvania (PDF 650KB); Large print version (PDF 843KB); Spanish version (PDF 813KB)
- Medicare Advantage Plan Guide: Southeast Pennsylvania (PDF 670KB); Large print version (PDF 895KB); Spanish version (PDF 807KB)
- Medicare Advantage Plan Guide: North & Central Pennsylvania (PDF 654KB); Large print version (PDF 849KB); Spanish version (PDF 789KB)
- Medicare Advantage Plan Guide: Outside of Pennsylvania (PDF 750KB); Large print version (PDF 992KB); Spanish version (PDF 911KB)
- Abridged Formulary (Revised December 2024; PDF 1.3MB)
- Comprehensive Formulary (December 2024; PDF 2MB)
- Part D Formulary Lookup Tool
- Annual Notice of Changes (Revised December 2024; PDF 916KB)
- Evidence of Coverage (PDF 1.4MB)
- Prior Authorization and Step Therapy criteria documents
- Gold5 Abridged Formulary (Revised December 2024;PDF 977KB)
- Gold5 Comprehensive Formulary (December 2024; PDF 1.6MB)
- Part D Formulary Lookup Tool
- Annual Notice of Changes (Revised December 2024; PDF 931KB)
- Evidence of Coverage (PDF 1.47MB)
- Prior Authorization and Step Therapy criteria documents
- CMS Appointment of an Authorized Representative Form (PDF 76KB)
- MTMP Enrollment Mailer (PDF 130KB)
- MTMP Recommended To-Do-List (Form CMS-10396) (PDF 123KB)
- MTMP Standardized Format Medication List (Form CMS-10396) (PDF 223KB)
Non-Medicare-Eligible
- HOP Pre-65 Medical Plan Guide (PDF 1.5MB)
- 2024 Pre-65 Medical Plan Summary Plan Description (SPD) (PDF 671KB)
- HOP Pre-65 Medical Plan Critical Care Drugs List (PDF 43KB)
- Medicare Advantage Plan Guide: Southwest Pennsylvania (PDF 650KB); Large print version (PDF 843KB); Spanish version (PDF 813KB)
- Medicare Advantage Plan Guide: Southeast Pennsylvania (PDF 670KB); Large print version (PDF 895KB); Spanish version (PDF 807KB)
- Medicare Advantage Plan Guide: North & Central Pennsylvania (PDF 654KB); Large print version (PDF 849KB); Spanish version (PDF 789KB)
- Medicare Advantage Plan Guide: Outside of Pennsylvania (PDF 750KB); Large print version (PDF 992KB); Spanish version (PDF 911KB)
Last Modified: January 3, 2025
Get Help
Contact the HOP Administration Unit for assistance with your questions.