Documents and Resources
2022 Plan Documents
Information Book
Annual Notice of Change
- 2022 Annual Notice of Change – HTA Plan I (MAPD-PPO)
- 2022 Annual Notice of Change – HTA Plan II (MAPD-PPO)
- 2022 Annual Notice of Change—HTA Diabetes & Heart Care (HMO CSNP)
Summary of Benefits
- 2022 Summary of Benefits – HealthTeam Advantage PPO
- 2022 Summary of Benefits – HealthTeam Advantage Diabetes & Heart Care Plan (HMO CSNP)
Provider/Pharmacy Directory
- 2022 Provider/Pharmacy Directory
- 2022 Find A Provider (Online Lookup)
- 2022 Find A Pharmacy (Online Lookup)
Dental Certificates of Coverage
- 2022 PPO I Dental Coverage Certificate with Covered Code List
- 2022 PPO II Dental Coverage Certificate with Covered Code List
- 2022 CSNP Dental Coverage Certificate with Covered Code List
- 2022 PPO I Dental Rider Coverage Certificate with Covered Code List
- 2022 PPO II Dental Rider Coverage Certificate with Covered Code List
- 2022 CSNP Dental Rider Coverage Certificate with Covered Code List
Low Income Subsidy
- Low Income Subsidy – HealthTeam Advantage PPO
- Low Income Subsidy – HealthTeam Advantage Diabetes & Heart Care Plan (HMO CSNP)
Included Features
Evidence of Coverage
- 2022 Evidence of Coverage – Health Plan I (PPO)
- 2022 Evidence of Coverage – Health Plan II (PPO)
- 2022 Evidence of Coverage – HealthTeam Advantage Diabetes and Heart Care Plan (HMO CSNP)
Enrollment Form
- 2022 Enrollment Online Form
- 2022 Enrollment Book – HealthTeam Advantage PPO
- 2022 Enrollment Book – HealthTeam Advantage CSNP
Supplemental Benefit
Comprehensive Formulary
- 2022 Comprehensive Formulary – HealthTeam Advantage PPO
- 2022 Comprehensive Formulary – HealthTeam Advantage Diabetes & Heart Care Plan (HMO CSNP)
- 2022 Comprehensive Formulary Addendum –HealthTeam Advantage PPO
- 2022 Comprehensive Formulary Addendum–HealthTeam Advantage Diabetes & Heart Care Plan (HMO CSNP)
- 2022 CSNP HTA Senior Savings Model for Insulin
Part D Pharmacy: Prior Authorization Criteria
- Prior Authorization Criteria HealthTeam Advantage PPO
- Prior Authorization Criteria HealthTeam Advantage Diabetes & Heart Care Plan (HMO CSNP)
- 2022 Prior Authorization Forms HealthTeam Advantage PPO
- 2022 Prior Authorization Forms HealthTeam Advantage Diabetes & Heart Care Plan (HMP CNSP)
Additional Forms
- Authorization for Release of Protected Health Information (PHI)
- Notice of Privacy Practices
- Health Risk Assessment – Online
- Health Risk Assessment – PDF
- Appointment of Representative
- Medicare Stars Rating (PPO)
- Medicare Stars Rating (HMO)
- HTA PPO 2022 Medical Direct Member Reimbursement Request
- HTA CSNP 2022 Medical Direct Member Reimbursement Request
- Delta Dental 2022 Direct Member Reimbursement Request
- VSP Vision 2022 Direct Member Reimbursement Request
- Understanding PPO Drug Payment Stages
- Understanding CSNP Drug Payment Stages
- General Request for Medicare Prescription Drug Coverage Determination