Prescriptions / Prescription Drug Tiers
Prescription Drug Tiers for Medicare Advantage Plans
HealthTeam Advantage Medicare Advantage Plans cover everything Medicare Parts A and B cover. Plus our benefits cover all the other things you need including Prescriptions, Dental, Vision, Hearing, Fitness, and more.
Use our Medicare Plan Comparison Tool to Easily Explore Plans
HealthTeam Advantage Plan I (PPO)Plan Details |
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|---|---|---|---|---|
| In-Network Retail | ||||
| Preferred Pharmacies | Standard Pharmacies | |||
Up to 30-Day Supply |
Up to 100-Day Supply |
Up to 30-Day Supply |
Up to 100-Day Supply |
|
| Tier 1 – Preferred Generics | $0 copay | $0 copay | $10 copay | $25 copay |
| Tier 2 – Generics | $5 copay | $12.50 copay | $20 copay | $50 copay |
| Tier 3 – Preferred Brands | $47 copay | $117.50 copay | $47 copay | $117.50 copay |
| Tier 4 – Non-Preferred Drugs | $100 copay | $250 copay | $100 copay | $250 copay |
| Tier 5 – Specialty Drugs | 33% coinsurance | 33% coinsurance | 33% coinsurance | 33% coinsurance |
| In-Network Mail-Order | ||||
| Up to 30-day supply | Up to 100-day supply | |||
| Tier 1 – Preferred Generics | $0 | $0 | ||
| Tier 2 – Generics | $5 | $12.50 | ||
| Tier 3 – Preferred Brands | $47 | $117.50 | ||
| Tier 4 – Non-Preferred Drugs | $100 | $250 | ||
| Tier 5 – Specialty Drugs | 33% | 33% | ||
HealthTeam Advantage Plan II (PPO)Plan Details |
||||
| In-Network Retail | ||||
| Preferred Pharmacies | Standard Pharmacies | |||
Up to 30-Day Supply |
Up to 100-Day Supply |
Up to 30-Day Supply |
Up to 100-Day Supply |
|
| Tier 1 – Preferred Generics | $0 copay | $0 copay | $0 copay | $0 copay |
| Tier 2 – Generics | $0 copay | $0 copay | $12 copay | $30 copay |
| Tier 3 – Preferred Brands | $47 copay | $117.50 copay | $47 copay | $117.50 copay |
| Tier 4 – Non-Preferred Drugs | $100 copay | $250 copay | $100 copay | $250 copay |
| Tier 5 – Specialty Drugs | 33% coinsurance | 33% coinsurance | 33% coinsurance | 33% coinsurance |
| In-Network Mail-Order | ||||
| Up to 30-day supply | Up to 100-day supply | |||
| Tier 1 – Preferred Generics | $0 | $0 | ||
| Tier 2 – Generics | $0 | $0 | ||
| Tier 3 – Preferred Brands | $47 | $117.50 | ||
| Tier 4 – Non-Preferred Drugs | $100 | $250 | ||
| Tier 5 – Specialty Drugs | 33% | 33% | ||
HealthTeam Advantage Vitality Plan (PPO)Plan Details |
||||
| In-Network Retail | ||||
| Preferred Pharmacies | Standard Pharmacies | |||
Up to 30-Day Supply |
Up to 100-Day Supply |
Up to 30-Day Supply |
Up to 100-Day Supply |
|
| Tier 1 – Preferred Generics | $0 copay | $0 copay | $10 copay | $25 copay |
| Tier 2 – Generics | $5 copay | $12.50 copay | $20 copay | $50 copay |
| Tier 3 – Preferred Brands | $47 copay | $117.50 copay | $47 copay | $117.50 copay |
| Tier 4 – Non-Preferred Drugs | 40% coinsurance | 40% coinsurance | 50% coinsurance | 50% coinsurance |
| Tier 5 – Specialty Drugs | 30% coinsurance | 30% coinsurance | 30% coinsurance | 30% coinsurance |
| In-Network Mail-Order | ||||
| Up to 30-day supply | Up to 100-day supply | |||
| Tier 1 – Preferred Generics | $0 | $0 | ||
| Tier 2 – Generics | $5 | $12.50 | ||
| Tier 3 – Preferred Brands | $47 | $117.50 | ||
| Tier 4 – Non-Preferred Drugs | 40% | 40% | ||
| Tier 5 – Specialty Drugs | 30% | 30% | ||
HealthTeam Advantage Cardinal Plan (HMO)Plan Details |
||||
| In-Network Retail | ||||
| Preferred Pharmacies | Standard Pharmacies | |||
Up to 30-Day Supply |
Up to 100-Day Supply |
Up to 30-Day Supply |
Up to 100-Day Supply |
|
| Tier 1 – Preferred Generics | $0 copay | $0 copay | $10 copay | $25 copay |
| Tier 2 – Generics | $5 copay | $12.50 copay | $20 copay | $50 copay |
| Tier 3 – Preferred Brands | $47 copay | $117.50 copay | $47 copay | $117.50 copay |
| Tier 4 – Non-Preferred Drugs | 40% coinsurance | 40% coinsurance | 50% coinsurance | 50% coinsurance |
| Tier 5 – Specialty Drugs | 33% coinsurance | 33% coinsurance | 33% coinsurance | 33% coinsurance |
| In-Network Mail-Order | ||||
| Up to 30-day supply | Up to 100-day supply | |||
| Tier 1 – Preferred Generics | $0 | $0 | ||
| Tier 2 – Generics | $0 | $0 | ||
| Tier 3 – Preferred Brands | $47 | $117.50 | ||
| Tier 4 – Non-Preferred Drugs | 40% coinsurance | 40% coinsurance | ||
| Tier 5 – Specialty Drugs | 33% coinsurance | 33% coinsurance | ||
HealthTeam Advantage Diabetes & Heart Care Plan (HMO C-SNP)Plan Details |
||||
| In-Network Retail | ||||
| Preferred Pharmacies | Standard Pharmacies | |||
Up to 30-Day Supply |
Up to 100-Day Supply |
Up to 30-Day Supply |
Up to 100-Day Supply |
|
| Tier 1 – Preferred Generics | $0 copay | $0 copay | $5 copay | $12.50 copay |
| Tier 2 – Generics | $0 copay | $0 copay | $15 copay | $37.50 copay |
| Tier 3 – Preferred Brands | $47 copay | $117.50 copay | $47 copay | $117.50 copay |
| Tier 4 – Non-Preferred Drugs | $100 copay | $250 copay | $100 copay | $250 copay |
| Tier 5 – Specialty Drugs | 31% coinsurance | 31% coinsurance | 31% coinsurance | 31% coinsurance |
| Tier 6 – Select Care Drugs | $0 | $0 | $0 | $0 |
| In-Network Mail-Order | ||||
| Up to 30-day supply | Up to 100-day supply | |||
| Tier 1 – Preferred Generics | $0 | $0 | ||
| Tier 2 – Generics | $0 | $0 | ||
| Tier 3 – Preferred Brands | $47 | $117.50 | ||
| Tier 4 – Non-Preferred Drugs | $100 | $250 | ||
| Tier 5 – Specialty Drugs | 31% coinsurance | 31% coinsurance | ||
| Tier 6 – Select Care Drugs | $0 | $0 | ||
Definition of the Six Drug Tiers
- Tier 1 – Preferred Generics: Generic drugs that are available at the lowest cost share
- Tier 2 – Generics: Generic and some very low-cost brand drugs that are available at a higher cost to you than drugs in Tier 1
- Tier 3 – Preferred Brands: Generic or brand drugs that are available at a lower cost to you than drugs in Tier 4
- Tier 4 – Non-Preferred Drugs: Generic or brand drugs that are available at a higher cost to you than drugs in Tier 3
- Tier 5 – Specialty Drugs: This is the highest-cost tier. Some injectables and other high-cost drugs
- Tier 6 – Select Care Drugs (only applies to CSNP plan): Generic or brand drugs that are used to treat or prevent conditions. Specifically, diabetes, cardiovascular disease and most vaccines.
Formulary
The Medicare program allows HealthTeam Advantage to make changes in our formulary at any time during the calendar year. A change in our formulary can affect which drugs are covered, the amount of copay, and limits on usage. If the plan makes any negative, non-maintenance formulary change, affected members will receive written notice that explains the change; the formulary on our website will also be updated.
For a list of changes made to the formulary, please see the formulary addendum available on the Plan Documents page.
Formulary Restrictions
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include prior authorization, step therapy, and quantity limits.
For more information on formulary restrictions, see the Formulary Restrictions page or review your Evidence of Coverage (EOC) document or Comprehensive Formulary available on the Plan Documents.
Need More Assistance?
Extra Help for
Prescription Costs
You may be able to get extra help pay for your prescription drug premiums and costs. To see if you qualify, call or contact:
1-800-Medicare (1-800-633-4227, TTY: 1-877-486-2048) Call anytime.
The Social Security Office at (1-800-772-1213, TTY: 1-800-325-0778) Call between 7 a.m. and 7 p.m. ET Monday through Friday.
Visit North Carolina Medicaid Office online.
For more information about gap coverage or other prescription drug benefits, please see your Evidence of Coverage in Plan Documents.
