HIRSP Policyholder Documents and Forms

Recent Notifications

Amendment to the HIRSP Policy Regarding Section 1 Amendment to the HIRSP Policy Regarding Emergency and Grace Period Amendment to the HIRSP HSA Policy Regarding Emergency and Grace Period HIRSP Prior-Approval Requirements Alert: ETHEX Corporation has issued a recall on a single lot of morphine sulfate 60 mg extended release tablets (Lot No. 91762) Actavis Totowa LLC has issued a recall of all Digitek® (digoxin) tablets for oral use See if a Lower Cost Tier 1 Alternative is Right for You Lower Cost Rx Alternatives Generic Alternatives Fexofenadine and Allegra-D will no longer be covered Neupro® (rotigotine transdermal system) patches manufactured by Schwarz Pharma recalled RxCents Tablet Splitting Program Duragesic, sold by PriCara, voluntarily recalled New Low-Cost Coverage Options for the Self-Employed, Including Farmers Using WALGREENS’ pharmacies may increase your out-of-pocket expenses Archived notices...

Applications and Enrollment	Download
Online Application for Coverage	Enroll online
Application Packet Memo 22333-021-0612	72 KB
Application for Coverage (Effective dates January 1, 2008 and later)	349 KB
Application for Reduced Premium, Deductible, and Drug Coinsurance	170 KB
Emergency Application For Reduced Premium, Deductible, And Drug Out-Of-Pocket Maximum	215 KB
Premium Rate Tables effective April 1, 2008 (For questions about claims submission/processing, please call 1-800-828-4777).	64 KB
HIPAA Privacy Authorization for Use or Disclosure Form	95 KB

Coverage and Policy Documents	Download
HIRSP Outline of Coverage	419 KB
HIRSP Policy for plans HIRSP 1,000; HIRSP 2,500; HIRSP 5,000.	146 KB
HIRSP Policy: HIRSP HSA Plan	144 KB
Other information about HIRSP is available under Chapter 149, Wis. Stats .
Understanding Your Explanation of Benefits Statement: Sample copy with notations explaining benefit information. 22247-021-0604	63 KB

Pharmacy Forms	Download
Preferred Drug List (Formulary)	Visit Navitus
Additional information about formulary (Will link to Pharmacy Benefit Administrator's Web site: Navitus)	Visit Navitus
HIRSP Prescription Drug Claim Form	24 KB
Prior Authorization Form for Compounded Drugs	23 KB
Navitus SpecialtyRx Notice	36 KB
Commonly Prescribed Specialty Pharmacy Products	57 KB
What is tablet splitting?	853 KB
HIRSP Expanded Pharmacy Networks	145 KB

Prior Authorization Forms	Download
Prior Authorization Forms (Will link to Pharmacy Benefit Administrator's Web site: Navitus)	Visit Navitus
Prior Authorization Process (Will link to Pharmacy Benefit Administrator's Web site: Navitus)	Visit Navitus
Prior Authorization Form for Compounded Drugs	23 KB

Privacy Forms	Download
HIRSP Notice of Privacy Practices	42 KB
Your Right to an Independent Review	64 KB
HIPAA Privacy Authorization for Use or Disclosure Form	68 KB
HIPAA Privacy Revocation of Authorization Form	62 KB
HIPAA Privacy Restriction Request Form	49 KB
HIPAA Privacy Access Request Form	55 KB
HIPAA Privacy Accounting Request Form	50 KB
HIPAA Privacy Alternative Communication Request Form	54 KB
HIPAA Privacy Amendment Request Form	44 KB
HIPAA Privacy Complaint Form	50 KB