Annual Notice of Change
- 2023 Annual Notice of Change – HTA Plan I (MAPD-PPO)
- 2023 Annual Notice of Change – HTA Plan I (MAPD-PPO) Errata
- 2023 Annual Notice of Change – HTA Plan II (MAPD-PPO)
- 2023 Annual Notice of Change – HTA Plan II (MAPD-PPO) Errata
- 2023 Annual Notice of Change – HTA Diabetes & Heart Care (HMO CSNP)
- 2023 Annual Notice of Change – HTA Diabetes & Heart Care (HMO CSNP) Errata
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)
Exclusive to CSNP Members
Evidence of Coverage
- 2023 Evidence of Coverage – Health Plan I (PPO)
- 2023 Evidence of Coverage – Health Plan I (PPO) Errata 11/15/22
- 2023 Evidence of Coverage – Health Plan I (PPO) Errata 03/01/23
- 2023 Evidence of Coverage – Health Plan II (PPO)
- 2023 Evidence of Coverage – Health Plan II (PPO) Errata 11/15/22
- 2023 Evidence of Coverage – Health Plan II (PPO) Errata 13/01/23
- 2023 Evidence of Coverage – HealthTeam Advantage Diabetes and Heart Care Plan (HMO CSNP)
- 2023 Evidence of Coverage – HealthTeam Advantage Diabetes and Heart Care Plan (HMO CSNP) Errata 11/15/22
- 2023 Evidence of Coverage – HealthTeam Advantage Diabetes and Heart Care Plan (HMO CSNP) Errata 03/01/23
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)
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