The Comparison of Pharmacy Benefits table below shows the amount or percentage you would pay for prescription drugs under each plan design. All covered prescription drugs (Rx) fall into one of four cost-sharing levels, including Level 1 for most generic drugs and Levels 2, 3 and 4 for most brand-name drugs.

You must use an in-network pharmacy when filling prescriptions. There is no coverage for prescriptions filled by out-of-network pharmacies.

To determine which level your drugs are in, see the Formulary at https://etf.benefits.navitus.com.

Provided By NAVITUS HEALTH SOLUTIONS
Navitus Toll-Free Customer Care—1-866-333-2757
www.navitus.com

Health Plan Design Access Plan  HDHP Design Access HDHP
Deductible1
An annual fixed dollar amount a member pays before the plan pays.
None $1,500 individual / $3,000 family (combined medical & Rx)
Copay/Coinsurance
A dollar amount or percentage a member pays for each covered drug.
Level 1 $5 After deductible:

$5

Level 2 20% ($50 max) After deductible:

20% ($50 max)

Level 3 40% ($150 max) After deductible:

40% ($150 max)

Level 4 Specialty
(Must fill at a specialty pharmacy)
$50 copay
After deductible:

$50 copay

Preventive Plan pays 100%, regardless of deductible Plan pays 100%, regardless of deductible
Out-of-Pocket Limits (OOPL)3
The maximum amount of copays, coinsurance or deductible that a member pays.
Levels 1 & 2 $600 individual / $1,200 family $2,500 individual / $5,000 family (combined medical & Rx)
Level 3 $6,850 individual / $13,700 family2,4
Level 4 $1,200 individual / $2,400 family

1Zero Dollar” preventive drugs identified by the Affordable Care Act (ACA) are paid for by the plan even if the deductible has not been met. “First Dollar” preventive drugs identified by the ACA are subject to copay/coinsurance cost sharing, even if the deductible has not been met. After the deductible is met, the member is still responsible for the copay/coinsurance until the OOPL is met.
2 Level 3 coinsurance does not apply toward the group health insurance program’s OOPL under a non-HDHP, only the federal maximum out-of-pocket (MOOP).
3 Family OOPLs for non-HDHP plans are embedded. An individual within a family can reach an individual OOPL before the family OOPL is met and not have to pay any copay/coinsurance. Family OOPLs for HDHP plans are not embedded and an individual will continue to pay until the family OOPL is met.
4 Federal Maximum Out-of-Pocket Limit or MOOP.


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Unless a drug is considered preventive, HDHP members are responsible for the full amount of the drug cost until the deductible is met, then the copays take effect until the annual out-of-pocket limit is met.

The most up-to-date formulary information is available at https://etf.benefits.navitus.com/.

You may also find the most up-to-date formulary on the Navitus website through the Navi-Gate for Members web portal. Go to the Navitus website and select the “Members” option on the left side of the page, then click on the “Member Login” link. Once logged in you can select the “Formulary” link on the left side of the page. You may also call Navitus Customer Care toll free at 1-866-333-2757 with questions about the formulary.

Some prescription drugs require a prior authorization to be covered by the plan. A prior authorization is initiated by the prescribing physician on behalf of the member. Navitus will review the prior authorization request within two business days of receiving all necessary information from your physician. Medications that require prior authorization for coverage are marked with “PA” on the formulary.

Diabetic supplies and glucometers are covered; you will pay 20% coinsurance. If you are a High Deductible Health Plan (HDHP) member, you will need to meet your deductible before benefits are payable.

A 90-day supply of most maintenance medications can be purchased at your retail pharmacy. To take advantage of this program, you must have three consecutive claims already processed for that drug in the Navitus claims system immediately before the 90-day supply is requested. In addition, your doctor must write the prescription specifically for a 90-day supply. Three copay are still required. More information can be found on the Navitus website or by calling Navitus Customer Care.

Serve You is the mail order vendor. Up to a 90-day supply of Level 1 and Level 2 medications can be purchased for only two copays through the mail order service. Level 3 medications may also be available for up to a 90-day supply, but three copays will apply. More detailed information can be found on the Navitus website, Serve You website, or by calling Navitus Customer Care.

By splitting a higher-strength tablet in half to provide the needed dose, you receive the same medication and dosage while buying fewer tablets and saving on copays. Medications included in the program are marked with “¢” on the Navitus formulary. Members may obtain tablet splitting devices at no cost by calling Navitus Customer Care.

If you are taking a specialty medication, the Navitus SpecialtyRx Program is offered through both Lumicera Specialty Pharmacy and UW Specialty Pharmacy for non-Medicare participants. Specialty medications are marked with “ESP” in the formulary. To begin receiving your self-injectable and other specialty medications from the specialty pharmacies, please call Navitus SpecialtyRx Customer Care at 1-877-651-4943.

Coordination of benefits applies when, as determined by the order of benefit determination rules, you have primary coverage under another policy and Navitus is your secondary coverage. All claims need to be submitted to your other policy first. Navitus covers the remaining cost of any covered prescriptions up to the allowed amount under your State Group Health plan. Coordination of benefits does not guarantee that all of your out-of-pocket costs will be covered.


last updated: 9/21/2018

Every effort has been made to ensure this information is current and correct. This page does not guarantee enrollment or the ability to make changes to your benefits.