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2024 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:

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HealthTeam Advantage PPO Plan I

	In-Network Retail (After you pay your deductible, if applicable)
	*Preferred Pharmacies**		Other Retail Pharmacies
Standard In-Network Retail or Mail-Orders	30-day supply	100-day supply	30-day supply	100-day supply
Tier 1 – Preferred Generics	$0 copay	$0 copay	$5 copay	$10 copay
Tier 2 – Generics	$5 copay	$10 copay	$15 copay	$30 copay
Tier 3 – Preferred Brands	$47 copay	$94 copay	$47 copay	$94 copay
Tier 4 – Non-Preferred Drugs	$100 copay	$200 copay	$100 copay	$200 copay
Tier 5 – Specialty Drugs	33% coinsurance	33% coinsurance	33% coinsurance	33% coinsurance

HealthTeam Advantage PPO Plan II

	In-Network Retail (After you pay your deductible, if applicable)
	*Preferred Pharmacies**		Other Retail Pharmacies
Standard In-Network Retail or Mail-Orders	30-day supply	100-day supply	30-day supply	100-day supply
Tier 1 – Preferred Generics	$0 copay	$0 copay	$0 copay	$0 copay
Tier 2 – Generics	$0 copay	$0 copay	$12 copay	$24 copay
Tier 3 – Preferred Brands	$47 copay	$94 copay	$47 copay	$94 copay
Tier 4 – Non-Preferred Drugs	$100 copay	$200 copay	$100 copay	$200 copay
Tier 5 – Specialty Drugs	33% coinsurance	33% coinsurance	33% coinsurance	33% coinsurance

HealthTeam Advantage HMO CSNP Plan

	In-Network Retail (After you pay your deductible, if applicable)
	*Preferred Pharmacies**		Other Retail Pharmacies
Standard In-Network Retail or Mail-Orders	30-day supply	100-day supply	30-day supply	100-day supply
Tier 1 – Preferred Generics	$0 copay	$0 copay	$5 copay	$10 copay
Tier 2 – Generics	$0 copay	$0 copay	$15 copay	$30 copay
Tier 3 – Preferred Brands	$47 copay	$94 copay	$47 copay	$94 copay
Tier 4 – Non-Preferred Drugs	$100 copay	$200 copay	$100 copay	$200 copay
Tier 5 – Specialty Drugs	31% coinsurance	31% coinsurance	31% coinsurance	31% coinsurance
Tier 6 – Select Care Drugs**	$0 copay	$0 copay	$0 copay	$0 copay

** Note: This includes select insulins. The Select Insulins are formulary insulins that are covered in Tier 6 of our Drug List and are being used for a diagnosis covered under Part D. Please note that if your insulin is being administered through a Part B covered insulin pump then the insulin must be covered under Part B and will not be eligible for the Part D copay.

HealthTeam Advantage Cardinal Plan HMO

	In-Network Retail (After you pay your deductible, if applicable)
	*Preferred Pharmacies**		Other Retail Pharmacies
Standard In-Network Retail or Mail-Orders	30-day supply	100-day supply	30-day supply	100-day supply
Tier 1 – Preferred Generics	$0 copay	$0 copay	$10 copay	$20 copay
Tier 2 – Generics	$5 copay	$10 copay	$20 copay	$40 copay
Tier 3 – Preferred Brands	$47 copay	$94 copay	$47 copay	$94 copay
Tier 4 – Non-Preferred Drugs	$100 copay	$200 copay	$100 copay	$200 copay
Tier 5 – Specialty Drugs	33% coinsurance	33% coinsurance	33% coinsurance	33% coinsurance

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.

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:

Give Us A Call

Prospective Members | TTY Users
866-897-4230 | 711

Current Members
888-965-1965 | 711

Providers
844-806-8217 (Option 5)

Agent & Brokers
855-547-0344

Prospective and Current Members Call From
October 1 to March 31, 7 days a week
8 AM – 8 PM ET

April 1 to September 30, Monday to Friday
8 AM – 8 PM ET

Providers Call From
Monday to Friday, 8 AM – 5:30 PM ET

Agents & Brokers Call From
Monday to Friday, 8 AM – 5 PM ET

Corporate

300 E. Wendover Ave. Suite 121 Greensboro, NC 27401

Local Benefit Center

5815 Samet Dr. Suite 107 High Point, NC 27265

Enrollment in HealthTeam Advantage depends on contract renewal. This information is not a complete description of benefits. Call for more information: prospective members call 866-393-3860, HTA PPO members call 888-965-1965, and HTA HMO CSNP members call 888-965-1965 (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.