Documents and Forms
Find a Plan Infographic (PDF 89KB); Large print version (PDF 63KB); Spanish version (PDF 77KB)
Notice of Availability of Language Assistance Services and Auxiliary Aids and 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 (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
2026 Medicare Star Rating (in Spanish)
- Enrollment Guide for Medicare-Eligible Members (PDF 3.1KB); Large print version (PDF 3.1KB); Spanish version (PDF 3.3KB)
- 2025 HOP Medical Plan Summary Plan Description (SPD) (PDF 522KB)
- 2025 Value Medical Plan Summary Plan Description (SPD) (PDF 282KB)
- Medicare.gov online supplier directory: Search for providers that cover Medicare Part B-eligible durable medical equipment, prostheses, orthotics, and supplies.
- Abridged Formulary (PDF 256 KB)
- Comprehensive Formulary (PDF 1.8 KB)
- Part D Formulary Lookup Tool
- Annual Notice of Change (PDF 378KB)
- Evidence of Coverage (PDF 2.12 MB)
- Prior Authorization and Step Therapy criteria documents
- Gold5 Abridged Formulary (PDF 320KB)
- Gold5 Comprehensive Formulary (PDF 1.4KB)
- Part D Formulary Lookup Tool
- Annual Notice of Change (PDF 249KB)
- Evidence of Coverage (PDF 2.12MB)
- 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 (PDF 123KB)
- MTMP Standardized Format Medication List (PDF 223KB)
MetLife Dental and EyeMed Vision Option Flyer (PDF 74 KB)
Non-Medicare-Eligible
- Enrollment Guide for Pre-65 Members (PDF 1.3MB)
- 2025 Pre-65 Medical Plan Summary Plan Description (SPD) (PDF 599KB)
- HOP Pre-65 Medical Plan Critical Care Drugs List (PDF 82KB)
Last Modified: November 25, 2025
Get Help
Contact the HOP Administration Unit for assistance with your questions.