Documents and Resources
2023 Plan Documents
Information Book
Annual Notice of Change
- 2023 Annual Notice of Change – HTA Plan I (MAPD-PPO)
- 2023 Annual Notice of Change – HTA Plan II (MAPD-PPO)
- 2023 Annual Notice of Change – HTA Diabetes & Heart Care (HMO CSNP)
Summary of Benefits
- 2023 Summary of Benefits – HealthTeam Advantage PPO
- 2023 Summary of Benefits – HealthTeam Advantage Diabetes & Heart Care Plan (HMO CSNP)
Provider and Pharmacy Information
- 2023 Provider/Pharmacy Directory
- Find A Provider (Online Lookup)
- 2023 Find A Pharmacy (Online Lookup)
- Understanding PPO Drug Payment Stages
- Understanding CSNP Drug Payment Stages
Part D: Pharmacy Utilization Criteria
- Prior Authorization Criteria HealthTeam Advantage PPO
- Prior Authorization Criteria HealthTeam Advantage Diabetes & Heart Care Plan (HMO CSNP)
- 2023 Prior Authorization Forms HealthTeam Advantage PPO
- 2023 Prior Authorization Forms HealthTeam Advantage Diabetes & Heart Care Plan (HMO CNSP)
- 2023 Step Therapy Criteria HealthTeam Advantage PPO
- 2023 Step Therapy Criteria HealthTeam Advantage Diabetes & Heart Care Plan (HMO CSNP)
Low Income Subsidy
- Low Income Subsidy – HealthTeam Advantage PPO
- Low Income Subsidy – HealthTeam Advantage Diabetes & Heart Care Plan (HMO CSNP)
Included Features
- Custodial Care
- Dental Health (PPO)
- Dental Health (CSNP)
- Fitness
- Healthcare Concierge
- Hearing Health
- Vision Health
- 24-Hour Nurse Advice Line
Exclusive to CSNP Members
Evidence of Coverage
- 2023 Evidence of Coverage – Health Plan I (PPO)
- 2023 Evidence of Coverage – Health Plan II (PPO)
- 2023 Evidence of Coverage – HealthTeam Advantage Diabetes and Heart Care Plan (HMO CSNP)
Enrollment Form
Comprehensive Formulary
- 2023 Comprehensive Formulary – HealthTeam Advantage PPO
- 2023 Comprehensive Formulary – HealthTeam Advantage Diabetes & Heart Care Plan (HMO CSNP)
- 2023 Comprehensive Formulary Addendum –HealthTeam Advantage PPO
- 2023 Comprehensive Formulary Addendum–HealthTeam Advantage Diabetes & Heart Care Plan (HMO CSNP)
Dental Certificates of Coverage
- 2023 PPO I Dental Coverage Certificate with Covered Code List
- 2023 PPO II Dental Coverage Certificate with Covered Code List
- 2023 CSNP Dental Coverage Certificate with Covered Code List
Additional Forms
- Automatic Bank Draft Authorization
- Authorization for Release of Protected Health Information (PHI)
- Health Risk Assessment – Online
- Health Risk Assessment – PDF
- Appointment of Representative
- Medicare Stars Rating PPO
- Medicare Stars Rating HMO
- HTA Medical Direct Member Reimbursement Request (PPO or CSNP)
- Delta Dental Direct Member Reimbursement Form
- VSP Vision Direct Member Reimbursement Form
- Prescription Drug Member Reimbursement Form
- General Request for Medicare Prescription Drug Coverage Determination