Policies & Procedures
Page last updated: October 01, 2023
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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.
| Care N’ Care Choice Premium (PPO) | Retail 30-day supply | Retail 100-day supply | Mail Order 30-day supply | Mail Order 100-day supply |
|---|---|---|---|---|
| Tier 1 – Preferred Generics Tier 2 – Generics Tier 3 – Preferred Brands – Formulary Insulins* Tier 4 – Non-Preferred Drugs Tier 5 – Specialty Drugs | $0 copay $8 copay $43 copay $35 copay $92 copay 33% of cost | $0 copay $16 copay $86 copay $70 copay $184 copay Not Covered | $0 copay $8 copay $43 copay $35 copay $92 copay 33% of cost | $0 copay $16 copay $86 copay $70 copay $184 copay Not Covered |
| Care N’ Care Choice Plus (PPO) | Retail 30-day supply | Retail 100-day supply | Mail Order 30-day supply | Mail Order 90-day supply |
| Tier 1 – Preferred Generics Tier 2 – Generics Tier 3 – Preferred Brands – Formulary Insulins* Tier 4 – Non-Preferred Drugs Tier 5 – Specialty Drugs | $2 copay $12 copay $45 copay $35 copay $97 copay 33% of cost | $4 copay $24 copay $90 copay $70 copay $194 copay Not Covered | $0 copay $12 copay $45 copay $35 copay $97 copay 33% of cost | $0 copay $24 copay $90 copay $70 copay $194 copay Not Covered |
| Care N’ Care Choice (PPO) | Retail 30-day supply | Retail 100-day supply | Mail Order 30-day supply | Mail Order 100-day supply |
| Tier 1 – Preferred Generics Tier 2 – Generics Tier 3 – Preferred Brands – Formulary Insulins* Tier 4 – Non-Preferred Drugs Tier 5 – Specialty Drugs | $4 copay $12 copay $47 copay $35 copay $100 copay 33% of cost | $8 copay $24 copay $94 copay $70 copay $200 copay Not Covered | $0 copay $12 copay $47 copay $35 copay $100 copay 33% of cost | $0 copay $24 copay $94 copay $70 copay $200 copay Not Covered |
| Care N’ Care Classic (HMO) | Retail 30-day supply | Retail 100-day supply | Mail Order 30-day supply | Mail Order 100-day supply |
| Tier 1 – Preferred Generics Tier 2 – Generics Tier 3 – Preferred Brands – Formulary Insulins* Tier 4 – Non-Preferred Drugs Tier 5 – Specialty Drugs | $0 copay $10 copay $47 copay $35 copay $100 copay 33% of cost | $0 copay $20 copay $94 copay $70 copay $200 copay Not Covered | $0 copay $10 copay $47 copay $35 copay $100 copay 33% of cost | $0 copay $20 copay $94 copay $70 copay $200 copay Not Covered |
| Southwestern Health Select (HMO) | Retail 30-day supply | Retail 100-day supply | Mail Order 30-day supply | Mail Order 100-day supply |
| Tier 1 – Preferred Generics Tier 2 – Generics Tier 3 – Preferred Brands – Formulary 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 Not Covered | $0 copay $0 copay $40 copay $35 copay $100 copay 33% of cost | $0 copay $0 copay $80 copay $70 copay $200 copay Not Covered |
* Tier 3 –Formulary Insulins: An insulin is a formulary insulin if it is listed on the Comprehensive Formulary (sometimes called the “Drug List”) found here.
Important Message About What You Pay for Vaccines – Our plan covers most Part D vaccines at no cost to you. Call your Customer Experience Team for more information.
Important Message About What You Pay for Insulin – You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on.
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 8 a.m. and 7 p.m. (CST) 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 2024 Plan Documents.
