CSNP Pharmacy Benefit
HTA PPO plans offer 5 Tiers for medication pricing:
Tier 1: preferred generic medications
Tier 2: other generic medications
Tier 3: preferred brand name medications
Tier 4: non preferred brand name and generic medications
Tier 5: Specialty Medications
The HMO CSNP plan for members with DM and/or heart failure, offers a 6th tier, which offers a special cost for select care medications (associated with the treatment of DM or CHF, including certain insulins). The costs for Tier 6 drugs are designed to encourage compliance with the medications which can most impact the target disease processes, DM and CHF.
Medications in Tier 6 have $0 copays up to the coverage gap (aka donut hole). CSNP also continues to offer $0 copays for generic medications and certain insulins during the coverage gap. Brand Name medications on Tier 6 have $0 copays until the Coverage Gap Phase. In the coverage gap, the copay for a brand name medication will be 25% of the negotiated pharmacy price (negotiated by the Plan, not the patient). A $95 deductible will apply to Tier 4 and 5 medications.
Initial Phase Copayments for CSNP are as follows:
| 30-day supply | 90-day supply | |
| Tier 1 – Preferred Generics | $0 copay | $0 copay |
| Tier 2 – Generics | $15 copay | $30 copay |
| Tier 3 – Preferred Brands | $45 copay | $90 copay |
| Tier 4 – Non-Preferred Drugs* | $100 copay | $200 copay |
| Tier 5 – Specialty Drugs* | 31% coinsurance | 31% coinsurance |
| Tier 6 – Select Care Drugs (includes Select Insulins) | $0 | $0 |
| * A $95 deductible applies for T4 and T5 medications | ||
Remember that for all HTA plans, prescribing a medication for 90 days will cost the equivalent of two 30-day copays (essentially giving the medication to the member for one month free) regardless of whether the member obtains the medication from a local retail pharmacy or mail order.
The formularies for the CSNP or PPO plans can be easily viewed online at the HealthTeam Advantage Plan Documents page:
January CSNP Formulary: https://healthteamadvantage.com/wp-content/uploads/2021/12/HTA_CSNP_2022_COMPREHENSIVE_01012022_12292021.pdf
January PPO Formulary: https://healthteamadvantage.com/wp-content/uploads/2021/12/HTA_5T_2022_COMPREHENSIVE_01012022_12222021.pdf
Another resource is the online drug lookup tool. Be sure to select whether you are looking for a medication on the PPO or CSNP plan.