Prescriptions / Prescription Drug Tiers
Prescription Drug Tiers for HealthTeam Advantage
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HealthTeam Advantage Plan I (PPO)Plan Details |
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|---|---|---|---|---|
| In-Network Retail | ||||
| Preferred Pharmacy | Standard Pharmacy | |||
Up to 30-Day Supply |
Up to 100-Day Supply |
Up to 30-Day Supply |
Up to 100-Day Supply |
|
| Tier 1 – Preferred Generic | $0 copayment | $0 copayment | $10 copayment | $30 copayment |
| Tier 2 – Generic | $3 copayment | $9 copayment | $15 copayment | $45 copayment |
| Tier 3 – Preferred Brand | 20% coinsurance | 20% coinsurance | 25% coinsurance | 25% coinsurance |
| Tier 4 – Non-Preferred Drug | 35% coinsurance | 35% coinsurance | 45% coinsurance | 45% coinsurance |
| Tier 5 – Specialty Tier (limited to a 30-day supply) | 30% coinsurance | NA | 30% coinsurance | NA |
| Mail Order | ||||
| Up to 30-day supply | Up to 100-day supply | |||
| Tier 1 – Preferred Generic | $0 copayment | $0 copayment | ||
| Tier 2 – Generic | $3 copayment | $9 copayment | ||
| Tier 3 – Preferred Brand | 20% coinsurance | 20% coinsurance | ||
| Tier 4 – Non-Preferred Drug | 35% coinsurance | 35% coinsurance | ||
| Tier 5 – Specialty Tier (limited to a 30-day supply) | 30% coinsurance | NA | ||
HealthTeam Advantage Plan II (PPO)Plan Details |
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| In-Network Retail | ||||
| Preferred Pharmacy | Standard Pharmacy | |||
Up to 30-Day Supply |
Up to 100-Day Supply |
Up to 30-Day Supply |
Up to 100-Day Supply |
|
| Tier 1 – Preferred Generic | $0 copayment | $0 copayment | $5 copayment | $15 copayment |
| Tier 2 – Generic | $0 copayment | $0 copayment | $15 copayment | $45 copayment |
| Tier 3 – Preferred Brand | 20% coinsurance | 20% coinsurance | 25% coinsurance | 25% coinsurance |
| Tier 4 – Non-Preferred Drug | 35% coinsurance | 35% coinsurance | 45% coinsurance | 45% coinsurance |
| Tier 5 – Specialty Tier (limited to a 30-day supply) | 31% coinsurance | NA | 31% coinsurance | NA |
| Mail Order | ||||
| Up to 30-day supply | Up to 100-day supply | |||
| Tier 1 – Preferred Generic | $0 copayment | $0 copayment | ||
| Tier 2 – Generic | $0 copayment | $0 copayment | ||
| Tier 3 – Preferred Brand | 20% coinsurance | 20% coinsurance | ||
| Tier 4 – Non-Preferred Drug | 35% coinsurance | 35% coinsurance | ||
| Tier 5 – Specialty Tier (limited to a 30-day supply) | 31% coinsurance | NA | ||
HealthTeam Advantage Vitality Plan (PPO)Plan Details |
||||
| In-Network Retail | ||||
| Preferred Pharmacy | Standard Pharmacy | |||
Up to 30-Day Supply |
Up to 100-Day Supply |
Up to 30-Day Supply |
Up to 100-Day Supply |
|
| Tier 1 – Preferred Generic | $0 copayment | $0 copayment | $10 copayment | $30 copayment |
| Tier 2 – Generic | $3 copayment | $9 copayment | $17 copayment | $51 copayment |
| Tier 3 – Preferred Brand | 20% coinsurance | 20% coinsurance | 25% coinsurance | 25% coinsurance |
| Tier 4 – Non-Preferred Drug | 35% coinsurance | 35% coinsurance | 45% coinsurance | 45% coinsurance |
| Tier 5 – Specialty Tier (limited to a 30-day supply) | 29% coinsurance | NA | 29% coinsurance | NA |
| Mail Order | ||||
| Up to 30-day supply | Up to 100-day supply | |||
| Tier 1 – Preferred Generic | $0 copayment | $0 copayment | ||
| Tier 2 – Generic | $3 copayment | $9 copayment | ||
| Tier 3 – Preferred Brand | 20% coinsurance | 20% coinsurance | ||
| Tier 4 – Non-Preferred Drug | 35% coinsurance | 35% coinsurance | ||
| Tier 5 – Specialty Tier (limited to a 30-day supply) | 29% coinsurance | NA | ||
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)Plan Details |
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| In-Network Retail | ||||
| Preferred Pharmacy | Standard Pharmacy | |||
Up to 30-Day Supply |
Up to 100-Day Supply |
Up to 30-Day Supply |
Up to 100-Day Supply |
|
| Tier 1 – Preferred Generic | $0 copayment | $0 copayment | $10 copayment | $30 copayment |
| Tier 2 – Generic | $0 copayment | $0 copayment | $20 copayment | $60 copayment |
| Tier 3 – Preferred Brand | 25% coinsurance | 25% coinsurance | 25% coinsurance | 25% coinsurance |
| Tier 4 – Non-Preferred Drug | 40% coinsurance | 40% coinsurance | 50% coinsurance | 50% coinsurance |
| Tier 5 – Specialty Tier (limited to a 30-day supply) | 29% coinsurance | NA | 29% coinsurance | NA |
| Tier 6 – Select Care Drug | $0 copayment | $0 copayment | $0 copayment | $0 copayment |
| Mail Order | ||||
| Up to 30-day supply | Up to 100-day supply | |||
| Tier 1 – Preferred Generic | $0 copayment | $0 copayment | ||
| Tier 2 – Generic | $0 copayment | $0 copayment | ||
| Tier 3 – Preferred Brand | 25% coinsurance | 25% coinsurance | ||
| Tier 4 – Non-Preferred Drug | 40% coinsurance | 40% coinsurance | ||
| Tier 5 – Specialty Tier (limited to a 30-day supply) | 29% coinsurance | NA | ||
| Tier 6 – Select Care Drug | $0 copayment | $0 copayment | ||
Definition of the Six Drug Tiers
- Tier 1 – Preferred Generic: Generic drugs that are available at the lowest cost share
- Tier 2 – Generic: 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 Brand: Generic or brand drugs that are available at a lower cost to you than drugs in Tier 4
- Tier 4 – Non-Preferred Drug: Generic or brand drugs that are available at a higher cost to you than drugs in Tier 3
- Tier 5 – Specialty Tier: This is the highest-cost tier. Some injectables and other high-cost drugs
- Tier 6 – Select Care Drug (only applies to C-SNP plan): Generic or brand drugs that are used to treat or prevent conditions. Specifically, diabetes, cardiovascular disease, and most vaccines.
Formulary Changes
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 page.
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.