| Applications and Enrollment | Download |
|---|---|
| Online Application for Coverage |
Enroll online |
| Application Packet Memo 22333-021-0612 |
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| Application for Coverage (Effective dates January 1, 2008 and later) | |
| Application for Reduced Premium, Deductible, and Drug Coinsurance | |
| Emergency Application For Reduced Premium, Deductible, And Drug Out-Of-Pocket Maximum | |
| Premium Rate Tables effective April 1, 2008 (For questions about claims submission/processing, please call 1-800-828-4777). |
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| HIPAA Privacy Authorization for Use or Disclosure Form |
| Coverage and Policy Documents | Download |
|---|---|
| HIRSP Outline of Coverage | |
| HIRSP Policy for plans HIRSP 1,000; HIRSP 2,500; HIRSP 5,000. | |
| HIRSP Policy: HIRSP HSA Plan | |
| 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 |
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| 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 | |
| Prior Authorization Form for Compounded Drugs | |
| Navitus SpecialtyRx Notice | |
| Commonly Prescribed Specialty Pharmacy Products | |
| What is tablet splitting? |
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| HIRSP Expanded Pharmacy Networks |
| 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 |
| Privacy Forms | Download |
|---|---|
| HIRSP Notice of Privacy Practices | |
| Your Right to an Independent Review | |
| HIPAA Privacy Authorization for Use or Disclosure Form | |
| HIPAA Privacy Revocation of Authorization Form | |
| HIPAA Privacy Restriction Request Form | |
| HIPAA Privacy Access Request Form | |
| HIPAA Privacy Accounting Request Form | |
| HIPAA Privacy Alternative Communication Request Form | |
| HIPAA Privacy Amendment Request Form | |
| HIPAA Privacy Complaint Form |