2022 Pharmacy Information

Copays or Coinsurance

During the Initial Coverage Stage, the plan pays its share of the cost of your covered prescription drugs, and you pay your share (your copayment or coinsurance amount). Your share of the cost will vary depending on the drug and where you fill your prescription. Below is a summary of your copay amount based on drug tier.

Retail
30-day supply
Retail
90-day supply
Mail Order
30-day supply
Mail Order
90-day supply
Care N’ Care Choice Premium (PPO)
Tier 1 – Preferred Generics
Tier 2 – Generics
Tier 3 – Preferred Brands
– Select Insulins*
Tier 4 – Non-Preferred Drugs
Tier 5 – Specialty Drugs
$0 copay
$10 copay
$40 copay
$35 copay
$90 copay
33% of cost
$0 copay
$20 copay
$80 copay
$70 copay
$180 copay
33% of cost
$0 copay
$10 copay
$40 copay
$35 copay
$90 copay
33% of cost
$0 copay
$20 copay
$80 copay
$70 copay
$180 copay
33% of cost
Care N’ Care Choice Plus (PPO)
Tier 1 – Preferred Generics
Tier 2 – Generics
Tier 3 – Preferred Brands
– Select Insulins*
Tier 4 – Non-Preferred Drugs
Tier 5 – Specialty Drugs
$2 copay
$12 copay
$45 copay
$35 copay
$95 copay
33% of cost
$4 copay
$24 copay
$90 copay
$70 copay
$190 copay
33% of cost
$0 copay
$12 copay
$45 copay
$35 copay
$95 copay
33% of cost
$0 copay
$24 copay
$90 copay
$70 copay
$190 copay
33% of cost
Care N’ Care Choice (PPO)
Tier 1 – Preferred Generics
Tier 2 – Generics
Tier 3 – Preferred Brands
– Select Insulins*
Tier 4 – Non-Preferred Drugs
Tier 5 – Specialty Drugs
$4 copay
$14 copay
$47 copay
$35 copay
$100 copay
33% of cost
$8 copay
$28 copay
$94 copay
$70 copay
$200 copay
33% of cost
$0 copay
$14 copay
$47 copay
$35 copay
$100 copay
33% of cost
$0 copay
$28 copay
$94 copay
$70 copay
$200 copay
33% of cost
Care N’ Care Classic (HMO)
Tier 1 – Preferred Generics
Tier 2 – Generics
Tier 3 – Preferred Brands
– Select Insulins*
Tier 4 – Non-Preferred Drugs
Tier 5 – Specialty Drugs
$0 copay
$12 copay
$45 copay
$35 copay
$100 copay
33% of cost
$0 copay
$24 copay
$90 copay
$70 copay
$200 copay
33% of cost
$0 copay
$12 copay
$45 copay
$35 copay
$100 copay
33% of cost
$0 copay
$24 copay
$90 copay
$70 copay
$200 copay
33% of cost
Southwestern Health Select (HMO)
Tier 1 – Preferred Generics
Tier 2 – Generics
Tier 3 – Preferred Brands
– Select Insulins*
Tier 4 – Non-Preferred Drugs
Tier 5 – Specialty Drugs
$0 copay
$10 copay
$40 copay
$35 copay
$100 copay
33% of cost
$0 copay
$20 copay
$80 copay
$70 copay
$200 copay
33% of cost
$0 copay
$0 copay
$40 copay
$35 copay
$100 copay
33% of cost
$0 copay
$0 copay
$80 copay
$70 copay
$200 copay
33% of cost

* Tier 3 – Select Insulins: You can identify Select Insulins by the abbreviation “SSM” found in the “Notes & Restrictions” column here.

Here’s a definition of the five drug tiers:

  • Tier 1 – Preferred Generics: (This is the lowest cost tier): Includes generic drugs that are available at the lowest cost share for this plan.
  • Tier 2 – Generics: Includes generic drugs that are available at a higher cost to you than drugs in Tier 1. Also includes some very low cost brand drugs.
  • Tier 3 – Preferred Brands: Includes preferred brand name drugs that are available at a lower cost to you than drugs in Tiers 4 and 5. Also includes some high cost generic medications which are available at a higher cost to you than drugs in Tiers 1 and 2.
  • Tier 4 – Non-Preferred Drugs: Includes brand and generic 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): Includes some injectables and other high-cost drugs.

Extra Help

You may be able to get extra help to pay for your prescription drug premiums and/or copays. 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. (EST) Monday through Friday. TTY:1-800-325-0778
  • The Texas Medicaid Office

For additional prescription drug benefit details, please refer to your Evidence of Coverage found in Plan Documents.

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