Annual Notice of Change
- 2024 Annual Notice of Change – HTA Plan I (MAPD-PPO)
2024 Annual Notice of Change – HTA Plan I (MAPD-PPO) Errata - 2024 Annual Notice of Change – HTA Plan II (MAPD-PPO)
2024 Annual Notice of Change – HTA Plan II (MAPD-PPO) Errata - 2024 Annual Notice of Change – HTA Diabetes & Heart Care (HMO CSNP)
2024 Annual Notice of Change – HTA Diabetes & Heart Care (HMO CSNP) Errata
Evidence of Coverage
- 2024 Evidence of Coverage – Health Plan I (PPO)
2024 Evidence of Coverage – Health Plan I (PPO) Errata - 2024 Evidence of Coverage – Health Plan II (PPO)
2024 Evidence of Coverage – Health Plan II (PPO) Errata - 2024 Evidence of Coverage – HealthTeam Advantage Eagle Plan (PPO)
- 2024 Evidence of Coverage – HealthTeam Advantage Eagle Plan (PPO) Errata
- 2024 Evidence of Coverage – HealthTeam Advantage Diabetes and Heart Care Plan (HMO CSNP)
- 2024 Evidence of Coverage – HealthTeam Advantage Cardinal Plan (HMO)
Part D: Pharmacy Utilization Criteria
- Prior Authorization Criteria HealthTeam Advantage PPO and Cardinal Plan
- Prior Authorization Criteria HealthTeam Advantage Diabetes & Heart Care Plan (HMO CSNP)
- 2024 Prior Authorization Forms HealthTeam Advantage PPO and Cardinal Plan (Coming soon!)
- 2024 Prior Authorization Forms HealthTeam Advantage Diabetes & Heart Care Plan (HMO CNSP) (Coming soon!)
- 2024 Step Therapy Criteria HealthTeam Advantage
Comprehensive Formulary
- 2024 Comprehensive Formulary – HealthTeam Advantage PPO I, PPO II, and Cardinal (HMO)
- 2024 Comprehensive Formulary – HealthTeam Advantage Diabetes & Heart Care Plan (HMO CSNP)
- 2024 Comprehensive Formulary Addendum – HealthTeam Advantage PPO I, PPO II, and Cardinal (HMO)
- 2024 Comprehensive Formulary Addendum – HealthTeam Advantage Diabetes & Heart Care Plan (HMO CSNP)
Dental Certificates of Coverage
Included Features
PPO
- Companionship Services (NEW)
- Custodial Care
- Dental Health
- Fitness
- Healthcare Concierge
- Hearing Health
- Meal Delivery (NEW)
- Memory Fitness (NEW)
- Nurse Advice Line
- OTC Benefit (NEW)
- Preferred Pharmacy (NEW)
- Vision Health
Eagle
- Companionship Services (NEW)
- Custodial Care
- Fitness
- Flexible Wallet Benefit (NEW)
- Healthcare Concierge
- Memory Fitness (NEW)
- Nurse Advice Line
- OTC Benefit (NEW)
- Transportation (NEW)
CSNP
- Care Management
- Companionship Services (NEW)
- Custodial Care
- Dental Health
- Fitness
- Healthcare Concierge
- Hearing Health
- Meal Delivery (NEW)
- Memory Fitness (NEW)
- Nurse Advice Line
- OTC Benefit
- Preferred Pharmacy (NEW)
- Transportation (NEW)
- Vision Health
Cardinal
Additional Forms
- Automatic Bank Draft Authorization
- Authorization for Release of Protected Health Information (PHI)
- Appointment of Representative
- Health Risk Assessment – Online
- Health Risk Assessment – PDF
- Medicare Star Ratings
- 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