Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
The Plan requires you or your physician to get prior authorization for certain drugs. This means you will need to get approval from HealthTeam Advantage before you fill your prescriptions. If you don’t get approval, we may not cover the drug. These drugs are listed in the drug formulary with the symbol “PA” for prior authorization.
- Download the PPO Prior Authorization Criteria document
- Download the HMO CSNP Prior Authorization Criteria document
- Download the blank Prior Authorization request form document
In some cases, HealthTeam Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, the Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. These drugs are listed in the drug formulary with the symbol “ST” for step therapy.
For certain drugs, the Plan limits the amount of the drug that we will cover. For example, HealthTeam Advantage provides 30 tablets per prescription for Januvia 100mg tablets. This may be in addition to a standard one-month or three-month supply. These drugs are listed in the drug formulary with the symbol “QL” for quantity limits followed by the quantity and day supply limitation. To find out if your medication has a Quantity Limit, please search for the medication on the Medication Look Up page or download the Comprehensive Formulary under the 2021 Plan Documents.
- Download the PPO Quantity Limit document
- Download the HMO CSNP Quantity Limit document
- Download the blank Quantity Limit Exception request form.
Non-formulary Exception Request
You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. For more information, please see your Evidence of Coverage document located on the 2021 Plan Documents page.
- Download the blank Non-formulary Exception request form.
Tier Exception Request
You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. For more details on which drugs you can request this type of exception, please see your Evidence of Coverage document located on the 2021 Plan Documents page.
- Download the blank Tier Exception request form.