Documents and Forms
Find a Plan Infographic (PDF 69KB); Large print version (PDF 64KB); Spanish version (PDF 78KB)
Multi-language Interpreter Services
General Forms
- If you are not enrolled in the Health Options Program: Application Form (PDF 149KB)
- If you are enrolled in the Health Options Program and looking to change your coverage: Change Form (PDF 78KB)
- CMS Appointment of Representative Form (Form CMS-1696) (PDF 73K)
- 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 73K)
Medicare-Eligible
- Enrollment Guide for Medicare-Eligible Members (PDF 1.72MB); Large print version (PDF 2.1MB); Spanish version (PDF 1.6MB)
- 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 663KB); Large print version (PDF 256KB); Spanish version (PDF 256KB)
- Medicare Advantage Plan Guide: Southeast Pennsylvania (PDF 676KB); Large print version (PDF 279KB); Spanish version (PDF 279KB)
- Medicare Advantage Plan Guide: North & Central Pennsylvania (PDF 722KB); Large print version (PDF 250KB); Spanish version (PDF 250KB)
- Medicare Advantage Plan Guide: Outside of Pennsylvania (PDF 816KB); Large print version (PDF 394KB); Spanish version (PDF 394KB)
- Abridged Formulary (PDF 562KB)
- Comprehensive Formulary (Effective April 2024) (PDF 2MB)
- Part D Formulary Lookup Tool
- Annual Notice of Changes (PDF 378KB)
- Evidence of Coverage (PDF 2.12 MB)
- Gold5 Abridged Formulary (PDF 320KB)
- Gold5 Comprehensive Formulary (Effective April 2024) (PDF 1.6MB)
- Part D Formulary Lookup Tool
- Annual Notice of Changes (PDF 249KB)
- Evidence of Coverage (PDF 1.73MB)
Non-Medicare-Eligible
- HOP Pre-65 Medical Plan Guide (PDF 1.3MB)
- 2024 Pre-65 Medical Plan Summary Plan Description (SPD) (PDF 671KB)
- HOP Pre-65 Medical Plan Critical Care Drugs List (PDF 82KB)
- Medicare Advantage Plan Guide: Southwest Pennsylvania (PDF 663KB); Large print version (PDF 256KB); Spanish version (PDF 256KB)
- Medicare Advantage Plan Guide: Southeast Pennsylvania (PDF 676KB); Large print version (PDF 279KB); Spanish version (PDF 279KB)
- Medicare Advantage Plan Guide: North & Central Pennsylvania (PDF 722KB); Large print version (PDF 250KB); Spanish version (PDF 250KB)
- Medicare Advantage Plan Guide: Outside of Pennsylvania (PDF 816KB); Large print version (PDF 394KB); Spanish version (PDF 394KB)
Last Modified: April 10, 2024
Get Help
Contact the HOP Administration Unit for assistance with your questions.