[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-278732-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-278732-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","psers-hop-enrollment-change-form-2025-change-request","PSERS  HOP Enrollment Change Form - 2025 - Change Request","","Health Options Program (HOP) enrollment change form for PSERS members who are enrolled in the Health Options Program and want to change coverage. Use this form to change coverage or terminate coverage for the retiree, spouse, and dependents, including email delivery preferences for Evidence of Coverage and pharmacy network listings. 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If you do not want to change coverage, do not complete the form.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What enrollment and authorization requirements must be met?",{"text":68,"@type":64},"You must sign and date the Change Form where indicated in the Statement of Authorization. You must be enrolled in both Medicare Parts A and B to enroll in the HOP or Value Medical Plan.",{"name":70,"@type":61,"acceptedAnswer":71},"Can this form be used to enroll in a managed care organization?",{"text":72,"@type":64},"No. Do not use this Change Form to enroll in a managed care organization.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},278732,1789512064,{"code":4,"msg":82,"data":83},"success",[84,89,93,98,103,108,112,117,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":135,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":80,"read_time":33},3573418547284,"https://eur-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","HOP Administration Unit  \nP. O. Box 1764 • Lancaster, PA 17608-1764  \nPhone: 1-800-773-7725 • Fax: 1-877-411-4921 •TTY Phone: 1-800-498-5428 Representatives are available 8:00 [a. m. to](a. m. to) 8:00 p. m., Monday to Friday.  \nEmail: [HOPAdminUnithb@luminarehealth.com](HOPAdminUnithb@luminarehealth.com)  \nIMPORTANT—PLEASE READ!  \n• Only use this form if you are currently enrolled in the Health Options Program and want to change your coverage. If you do not want to change your coverage, DO NOT complete this form.  \n• YOU MUST sign and date the Change Form where indicated in the Statement of Authorization.  \n• YOU MUST be enrolled in BOTH Medicare Parts A AND B to enroll in the HOP or Value Medical Plan. YOU MUST be enrolled in EITHER Medicare Part A OR B to enroll in a Medicare Rx Option with no medical coverage.  \n • A retiree and spouse or dependent MUST apply for the same or comparable coverage.   \n • DO NOT use this Change Form to enroll in a managed care organization.   \nI want to (check all that apply):  \nChange coverage for:  \n❍ Myself  \n❍ My spouse  \n❍ My dependents  \nTerminate coverage for:  \n❍ Myself  \n❍ My spouse  \n❍ My dependents  \nRETIREE INFORMATION  \n\n| Name (as it appears on your Medicare card) | Last |  | First |  | MI |\n| --- | --- | --- | --- | --- | --- |\n| Permanent Address | Street (no P.O. boxes) |  |  | City |  |\n|  | State | Zip |  | County |  |\n| Mailing Address (if different from above) | Street |  |  | City |  |\n|  | State | Zip |  | County |  |\n\nBirth Date (mm/dd/yy)  \n\n| Home Phone \\# ( ) | Cell Phone \\# ( ) |\n| --- | --- |\n\nSocial Security Number  \n\n| Medicare Information | Medicare Number |  |\n| --- | --- | --- |\n|  | Part A Effective\u003Cbr>Date (mm/dd/yy) | Part B Effective\u003Cbr>Date (mm/dd/yy) |\n\nE3014_HOPEnrollmentChange_C PLEASE CONTINUE TO NEXT PAGE  \n\n| RETIREE INFORMATION |  |  |\n| --- | --- | --- |\n| Are you Hispanic, Latino/a, or Spanish origin? Select all that apply.*\u003Cbr>❍ No, not of Hispanic, Latino/a, or Spanish origin\u003Cbr>❍ Yes, Mexican, Mexican American, Chicano/a\u003Cbr>❍ Yes, Puerto Rican\u003Cbr>❍ Yes, Cuban\u003Cbr>❍ Yes, another Hispanic, Latino/a, or Spanish origin\u003Cbr>❍ I choose not to answer. |  |  |\n| What’s your race? Select all that apply.* |  |  |\n| ❍ American Indian or Alaska Native | ❍ | Native Hawaiian |\n| ❍ Asian Indian | ❍ | Other Asian |\n| ❍ Black or African American | ❍ | Other Pacific Islander |\n| ❍ Chinese | ❍ | Samoan |\n| ❍ Filipino/a | ❍ | Vietnamese |\n| ❍ Guamanian or CHamoru | ❍ | White |\n| ❍ Japanese\u003Cbr>❍ Korean | ❍ | I choose not to answer. |\n| I want to get the following materials via email. Select one or more.\u003Cbr>❍ Evidence of Coverage (EOC)\u003Cbr>❍ Listing of retail network pharmacies\u003Cbr>E-mail address:  |  |  |\n| Will you have other medical coverage (besides the Health Options Program and Medicare) when your Health Options Program coverage begins?\u003Cbr>Retiree ❍ Yes ❍ No Spouse** ❍ Yes ❍ No\u003Cbr>If yes, name of other insurance company: \u003Cbr>If no, did you drop an existing policy to enroll in the Health Options Program? ❍ Yes ❍ No |  |  |\n\n* Optional question: Answering this question is your choice. You can’t be denied coverage because you do not complete this question.  \n** Only complete if you are enrolling your spouse.  \nPLEASE CONTINUE TO NEXT PAGE  \nDEPENDENT INFORMATION (Complete this section ONLY if you are adding a dependent to your coverage for the first time or you are making a change to your dependent’s coverage. If more than one dependent is enrolling, please provide the requested information on an additional application. )  \nRelationship to PSERS Retiree ❍ Spouse ❍ Child (Call the HOP Administration Unit at  \n1-800-773-7725 before enrolling a child.)  \n\n| Name | Last |  | First |  | MI |\n| --- | --- | --- | --- | --- | --- |\n| Permanent Address | Street (no P.O. boxes) |  |  | City |  |\n|  | State | Zip |  | County |  |\n| Mailing Address (if different from above) | Street |  |  | City |  |\n|  | State | Zip |  | County |  |\n\nBirth Date (mm/dd/yy)  \n\n| Home Phone \\# ( ","cbCaiqtGA04lxSyk","https://ap.wps.com/l/cbCaiqtGA04lxSyk","pdf",704099,10,"English","# Change Request Instructions\n# Enrollment Change Selections\n# Retiree Information\n## Coverage and Medicare Details\n# Dependent Information\n## Relationship and Eligibility\n# Reason for Coverage Change Request","[{\"question\":\"When should this HOP change form be used?\",\"answer\":\"Use it only if currently enrolled in the Health Options Program and you want to change your coverage. If you do not want to change coverage, do not complete the form.\"},{\"question\":\"What enrollment and authorization requirements must be met?\",\"answer\":\"You must sign and date the Change Form where indicated in the Statement of Authorization. You must be enrolled in both Medicare Parts A and B to enroll in the HOP or Value Medical Plan.\"},{\"question\":\"Can this form be used to enroll in a managed care organization?\",\"answer\":\"No. Do not use this Change Form to enroll in a managed care organization.\"}]","PSERS  HOP Enrollment Change Form - 2025 - Change Request | PDF"]