2024 Part D Coverage Determinations

HealthTeam Advantage wants to provide thorough coverage and satisfactory service for your prescription drug coverage. You have the right to submit a coverage determination, appeal or grievance, if needed. This page describes how and why to submit coverage determinations. For more information on submitting a Part D drug appeal or grievance, please see the Part D Appeals and Grievances page. For additional information on Part D coverage determinations, appeals and grievances, see your Evidence of Coverage which can be downloaded on the 2024 Plan Documents page.

How to request a coverage determination

As a HealthTeam Advantage member, you, your Appointed Representative, or your prescribing physician may request a coverage determination. You or your appointed representative (your doctor, attorney, advocate, relative, friend or other person authorized to act on your behalf) can submit an online request, call, fax or mail in a request for a coverage determination as described below. We prefer that you have your prescribing physician submit an online request or fax RxAdvance with a supporting statement for your request.

• ONLINE: Coming Soon
• FAX: To fax your request, complete the correct coverage determination request form and fax to RxAdvance at 866-871-8565. These forms can be found on the Formulary Restrictions page. If you’re not sure which form to use, you can complete a general request form called the Request for Medicare Prescription Drug Coverage Determination (Coming soon).
• Mail: Please complete the correct coverage determination request form which can be found on the Formulary Restrictions page. If you’re not sure which form to use, you can complete a general request form called the Request for Medicare Prescription Drug Coverage Determination (Coming soon).

How to ask us to pay for a prescription drug you already received

You can ask us to pay for our share of the cost of a drug you have already received where you didn’t use your HealthTeam Advantage prescription drug benefits. This is called a Part D Direct Member Reimbursement request. For information on situations in which you may ask us for reimbursement of prescription drugs, please see your Evidence of Coverage which can be downloaded on the 2024 Plan Documents page.

To request reimbursement, please download the direct member reimbursement form and follow the instructions to complete the form on page 2. Submit the form AND the original paid pharmacy receipts to one of the following:

• BY MAIL:

RxAdvance/HealthTeam Advantage
Attn.: DMR Department
PO BOX 504
Southborough, MA 01772

• BY FAX: Fax your request to RxAdvance at 866-871-8565.

Once we receive your reimbursement request, a decision will be made within 14 calendar days. If approved, payment will be processed and mailed within the same 14 calendar days. If we deny any part of your request, we will provide instructions on how to appeal our decision. For more information on appealing a denied request, please see your Evidence of Coverage, which can be downloaded from the 2024 Plan Documents page. For questions regarding the process or status of your request please call RxAdvance.

HealthTeam Advantage Plan I and Plan II PPO members call RxAdvance at 1-800-237-1992 (TTY:711)

HealthTeam  Advantage Diabetes & Heart Care HMO members call RxAdvance at 1-800-459-0984 (TTY:711)

Complaints and Disenrollment

If you have a complaint, you can complain to Medicare. You can also end your enrollment. To do that, refer to the information about disenrollment on the Your Rights page.