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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

2025 HAP Medicare Plans

HAP Medicare Connect and HF Tiered Access (HMO) plans

HAP Medicare MSU-HC (HMO) and (PPO) plans

HAP MedicalAccess (HMO) plan

Henry Ford Select (HMO) plan

HAP Member Assist (PPO) plan

HAP Senior Plus (HMO-POS) plan

HAP Senior Plus and HAP Medicare Explore (PPO) Plans

HAP Medicare Complete Duals (HMO D-SNP) (PPO D-SNP) plans

2026 HAP Medicare plans

HAP Medicare Connect (HMO)

HAP Medicare Superior (HMO)

HAP Senior Plus Henry Ford Tiered Access (HMO)

Henry Ford Select (HMO)

HAP Medicare MedicalAccess (HMO)

HAP Medicare Diabetes and Heart (HMO C-SNP)

HAP Medicare Explore (PPO)

HAP Member Assist (PPO)

HAP Medicare Prime (PPO)

HAP Senior Plus (PPO)

HAP Senior Plus (HMO-POS)

HAP Medicare Complete Duals (HMO D-SNP)

HAP Medicare Complete Assist (PPO D-SNP)
Evidence of Coverage

2025 HAP Medicare plans

HAP Medicare Connect (HMO)

HAP Medicare MSU-HC (HMO)

HAP Senior Plus Henry Ford Tiered Access (HMO)

Henry Ford Select (HMO)

HAP Medicare MedicalAccess (HMO)

HAP Medicare Explore (PPO)

HAP Member Assist (PPO)

HAP Medicare MSU-HC Prime (PPO)

HAP Senior Plus (PPO)

HAP Senior Plus (HMO-POS)

HAP Medicare Complete Duals (HMO D-SNP)

HAP Medicare Complete Assist (PPO D-SNP)

2026 HAP Medicare plans

HAP Medicare Connect (HMO)

HAP Medicare Superior (HMO)

HAP Senior Plus Henry Ford Tiered Access (HMO)

Henry Ford Select (HMO)

HAP Medicare MedicalAccess (HMO)

HAP Medicare Diabetes and Heart (HMO)

HAP Medicare Explore (PPO)

HAP Member Assist (PPO)

HAP Medicare Prime (PPO)

HAP Senior Plus (PPO)

HAP Senior Plus (HMO-POS)

HAP Medicare Complete Duals (HMO D-SNP)

HAP Medicare Complete Assist (PPO D-SNP)
Annual Notice of Changes

2025 HAP Medicare plans

HAP Medicare Connect (HMO)

HAP Senior Plus Henry Ford Tiered Access (HMO)

HAP Medicare MedicalAccess (HMO)

HAP Medicare MSU-HC (HMO)

HAP Senior Plus (HMO-POS)

HAP Senior Plus (PPO)

HAP Medicare Explore (PPO)

HAP Medicare Complete Duals (HMO D-SNP)

2026 HAP Medicare plans

HAP Medicare Connect (HMO)

HAP Senior Plus Henry Ford Tiered Access (HMO)

HAP Medicare MedicalAccess (HMO)

HAP Medicare Superior (HMO)

HAP Henry Ford Select (HMO)

HAP Senior Plus (HMO-POS)

HAP Senior Plus (PPO)

HAP Medicare Explore (PPO)

HAP Medicare Prime (PPO)

HAP Member Assist (PPO)

HAP Medicare Complete Duals (HMO D-SNP)

HAP Medicare Complete Assist (PPO D-SNP)
Pharmacy forms

Pharmacy Advantage Enrollment Form
Drug formulary information

2025

2025 HAP Drug Formulary

2025 Prior Authorization Criteria

2025 Step Therapy Criteria

2026

2026 HAP Drug Formulary
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.
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

HAP Provider Verification of C-SNP Chronic Condition

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HAP Senior Plus (HMO-POS), HAP Medicare MedicalAccess (HMO), HAP Senior Plus Henry Ford Tiered Access (HMO), HAP Medicare Connect (HMO), HAP Medicare Superior (HMO), Henry Ford Select (HMO), HAP Senior Plus (PPO), HAP Medicare Explore (PPO), HAP Medicare Prime (PPO), HAP Member Assist (PPO), HAP Medicare Diabetes and Heart (HMO C-SNP), and HAP CareSource™ MI Coordinated Health (HMO D-SNP) has a contract with Medicare. Enrollment depends on contract renewal.

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Important forms and documents

2025 HAP Medicare Plans

2026 HAP Medicare plans

2025 HAP Medicare plans

2026 HAP Medicare plans

2025 HAP Medicare plans

2026 HAP Medicare plans

2025

2026

Manage your Medicare benefits and view personalized plan information

HAP and Henry Ford

Request a Medicare brochure

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