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2020 Pharmacy 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 & 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 (This includes Select Insulins)
$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 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: 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:

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