2020 Prescription Coverage

Plan

INFORMATION

Copays or Coinsurance

All drugs on HealthTeam Advantage’s drug list are in one of five cost-sharing tiers for the PPO plans and six cost-sharing tiers for the HMO CSNP plan. Below is a summary of copays depending on drug tier and plan:

	Standard In-Network Retail or Mail-Order (up to a 30-day supply)	Standard In-Network Retail or Mail-Order (up to a 90-day supply)
HealthTeam Advantage Plan I (PPO)
Tier 1 – Preferred Generics Tier 2 – Generics Tier 3 – Preferred Brands Tier 4 – Non-Preferred Drugs Tier 5 – Specialty Drugs	$5 copay $15 copay $45 copay $90 copay 33% coinsurance	$10 copay $30 copay $90 copay $180 copay 33% coinsurance
HealthTeam Advantage Plan II (PPO)
Tier 1 – Preferred Generics Tier 2 – Generics Tier 3 – Preferred Brands Tier 4 – Non-Preferred Drugs Tier 5 – Specialty Drugs	$0 copay $12 copay $40 copay $80 copay 33% coinsurance	$0 copay $24 copay $80 copay $160 copay 33% coinsurance
HealthTeam Advantage diabetes and Heart Care (HMO CSNP)
Tier 1 – Preferred Generics Tier 2 – Generics Tier 3 – Preferred Brands Tier 4 – Non-Preferred Drugs Tier 5 – Specialty Drugs Tier 6 – Select Care Drugs	$0 copay $15 copay $45 copay $90 copay 33% coinsurance $0	$0 copay $30 copay $90 copay $180 copay 33% coinsurance $0

Definition of the five 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 – Specialty Drugs: Generic or brand drugs that are used to treat or prevent conditions. Specifically, diabetes, cardiovascular disease and most vaccines.

Extra Help

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) anytime

The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m. ET Monday through Friday. TTY: 1-800-325-0778

The North Carolina Medicaid Office.

For more information about gap coverage or other prescription drug benefits, please see your:

HealthTeam Advantage, a product of Care N’ Care Insurance Company of North Carolina, Inc., is a Medicare Advantage plan with a Medicare contract. Enrollment in HealthTeam Advantage depends on contract renewal. This information is not a complete description of benefits. Call for more information: prospective members call 877-905-9216 , HTA PPO members call 888-965-1965, and HTA CSNP members call 833-324-3242 (TTY:711) from October 1–March 31, 8 a.m. to 8 p.m. ET, seven days a week, or April 1–September 30, 8 a.m. to 8 p.m. ET, Monday through Friday. Medicare beneficiaries may also enroll in HealthTeam Advantage through the CMS Medicare Online Enrollment Center located at http://medicare.gov. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

Every year, Medicare evaluates plans based on a 5-star rating system.

Plan

INFORMATION