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Coverage and Enrollment Forms

Choice of Coverage Documents

• HIRSP Introduction letter regarding choice of coverage
• HIRSP Choice of Coverage Request Application
• HIRSP Federal Introduction letter
• HIRSP Federal Choice of Coverage Request Application

HIRSP offers 3 plan options

• The HIRSP Plan is for an individual who has recently been insured.
• The HIRSP Federal Plan is for individuals who have not been insured for at least six months.
• HIRSP Medicare Supplement Plan is for individuals who are on Medicare because of a disability or for current HIRSP members who turn 65 while enrolled in HIRSP.

Please use the link below to help you compare the plan options.

Compare Plans

• View a Comparison of HIRSP and HIRSP Federal Plans

HIRSP Coverage	HIRSP Federal Coverage
Outline of Coverage Policy for plans HIRSP 1,000; HIRSP 2,500; HIRSP 5,000. Policy for the HIRSP HSA Plan (PDF)	HIRSP Federal Plan - Outline of Coverage Policy - HIRSP Federal Plans Learn more about the HIRSP Federal Plan

HIRSP Enrollment	HIRSP Federal Enrollment
Applications HIRSP Application for Coverage Application for Reduced Premium, Deductible, and Drug Out-of-Pocket Maximum. Emergency Application For Reduced Premium, Deductible, And Drug Out-Of-Pocket Maximum	Federal Application HIRSP Federal Application for Coverage No federal subsidy applicable. No emergency application applicable.
Rate Information HIRSP Premium Rate Tables effective Jan 1 2012 2012 HIRSP Medicare Supplement Rate Tables	HIRSP Federal Rate Information HIRSP Federal Rate Tables (for effective dates August 1 and after)
HIPAA Authorization Form

MedTrak Pharmacy Services

For formulary and pharmacy benefit information please visit the HIRSP Pharmacy Benefit Administrator's site:

>> MedTrak Pharmacy Services