Pharmacy benefits are included in all State Group Health Insurance plan designs. Navitus Health Solutions administers the pharmacy benefits.
All plan designs require the use of an in-network pharmacy. For this reason, it is important to confirm that your pharmacy is an in-network pharmacy by reviewing the In-Network Pharmacy document provided in the Forms & Resources section below or by calling Navitus at 866-333-2757.
All covered prescriptions are categorized into one of four cost-sharing levels. Level 1 contains most generic drugs (least expensive) whereas Levels 2, 3 and 4 contain most brand-name drugs.
Employees pay either a copay (flat dollar amount) or coinsurance (percentage) based on the level the drug is categorized as until the annual out-of-pocket limit is met. If enrolled in a High Deductible Health Plan (HDHP), the deductible will need to be met before the copay or coinsurance applies.
- Review the Navitus Formulary List in the Forms & Resources section below to determine which level your prescription drugs fall into. The most current list may be found at www.navitus.com (after login).
- Review the Comparison of Health and Pharmacy Benefits in the Forms & Resources section below to see how prescription drugs are covered by each plan design.
- Review the Certificate of Coverage in the Forms & Resources section below for detailed information regarding pharmacy benefits.
Note: Separate ID cards are issued by the health insurance plan carrier and Navitus, the pharmacy benefits administrator.
Some prescription drugs require prior authorization. A prior authorization is initiated by the prescribing physician on behalf of the member. Navitus will review the prior authorization request within 48 hours of receiving all necessary information from the physician. Medications that require prior authorization are marked with “PA” on the “Navitus Formulary List” in the Forms & Resources section below.
Coordination of Benefits
Coordination of benefits applies when you have coverage under Navitus and another policy with pharmacy benefits. The order of benefit determination rules determine which coverage is primary and which coverage is secondary. Usually, the other policy is primary and Navitus is secondary. This means that all pharmacy claims are submitted to your other policy first and Navitus may cover the remaining cost up to the allowed amount under your State Group Health Insurance plan. Coordination of benefits does not guarantee that all of your out-of-pocket costs will be covered.
By splitting a higher-strength tablet in half to provide the needed dose, the same medication and dosage is received while buying fewer tablets (saving you money on copays). Participation in RxCents Tablet-Splitting is voluntary. Medications included in the program are marked with “¢” on the “Navitus Formulary List” in the Forms & Resources section below.
Specialty medications are used to treat complex chronic and/or life threatening conditions. The Navitus SpecialtyRx Program is offered through both Lumicera Health Services and UW Health Specialty Pharmacy for non-Medicare participants. To begin receiving specialty medications from one of the specialty pharmacies, call Lumicera Health Services at 855-847-3553 or UW Health Specialty Pharmacy at 866-894-3784. Specialty medications are marked with “ESP” on the “Navitus Formulary List” in the Forms & Resources section below.
90-Day at Retail Program
A 90-day supply of most maintenance medications can be purchased at a retail pharmacy. Maintenance medications are prescriptions taken on a regular, recurring basis. To use this program, a member must have three consecutive, 30-day supply claims processed for that drug in Navitus’ claims system. In addition, the doctor must write the prescription specifically for a 90-day supply. Three copays are still required. More information can be found on the Navitus website or by calling Navitus.
Mail Order Program
The use of mail order is recommended for drugs used to treat chronic, long-term conditions. 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 information can be found on the Navitus website, Serve You website, or by calling Navitus.
The pharmacy benefit premiums are included in the State Group Health Insurance premiums. Review the Premiums page for the State Group Health Insurance premiums.
Forms & Resources
- Certificate of Coverage
- In-Network Pharmacy
- Terms and Conditions
- Navitus Health Solutions | 1-866-333-2757
last updated: 06/24/2019
Every effort has been made to ensure this information is current and correct. Information on this page does not guarantee enrollment, benefits and/or the ability to make changes to your benefits.