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) |
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| 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 $100 copay 33% coinsurance |
$10 copay $30 copay $90 copay $200 copay 33% coinsurance |
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| 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 |
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| HEALTHTEAM ADVANTAGE DIABETES AND HEART CARE (HMO CSNP) | Tiers 4 & 5 only: $95 (Deductible must be met before the cost-share listed below is applied) | ||
| 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 (includes Select Insulins) |
$0 copay $15 copay $45 copay $100 copay 31% coinsurance $0 |
$0 copay $30 copay $90 copay $200 copay 31% coinsurance $0 |
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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: