Pharmacy Benefits

Overview

Pharmacy benefits are included in all State Group Health Insurance plan designs. Navitus Health Solutions administers the pharmacy benefits.

Pharmacy Network

All plan designs require the use of an in-network pharmacy. Confirm that your pharmacy is in-network at www.navitus.com or by calling Navitus at (866) 333-2757.

Pharmacy Benefits

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.

You pay either a copay (flat dollar amount) or coinsurance (percentage) based on the level the drug is categorized as. This continues until the annual out-of-pocket limit is met. If enrolled in a High Deductible Health Plan (HDHP), the deductible must be met before the copay or coinsurance applies. Use the resources available in the Forms & Resources section to help you determine the out-of-pocket cost for your prescription drugs .

• Navitus Formulary List: Use this list to determine which level your prescription drug is categorized as.
• Comparison of Health and Pharmacy Benefits: Use this comparison to see how prescription drugs are covered by each plan design.
• Certificate of Coverage: Provides detailed information about how pharmacy benefits are covered.

Note: Separate ID cards are issued by the health insurance plan carrier and Navitus, the pharmacy benefits administrator. You can register and login to print a pharmacy benefits ID card online at www.navitus.com.

Prior Authorization

Some prescription drugs require prior authorization. A prior authorization is initiated by the prescribing physician on your behalf. 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.”

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 second. 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 out-of-pocket costs will be covered.

RxCents Tablet-Splitting

By splitting a higher-strength tablet in half to provide the needed dose, the same medication and dosage is received while buying fewer tablets. This may save you money on copays. Participation in RxCents Tablet-Splitting is voluntary. Medications included in the program are marked with “¢” on the “Navitus Formulary List.”

Specialty Medications

Specialty medications are used to treat complex chronic or life threatening conditions. The Navitus SpecialtyRx Program is offered through Lumicera Health Services and UW Health Specialty Pharmacy for non-Medicare participants. To receive 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.”

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 by Navitus. In addition, the doctor must write the prescription for a 90-day supply. Three copays are 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 prescription 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 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.

ID Cards

If you enroll in State Group Health Insurance, you will receive an ID card for healthcare services and a separate ID card for pharmacy benefits.

Present your pharmacy ID card at the pharmacy when you pick-up your prescriptions or if you use mail order services.

To request a new pharmacy benefits ID card, go to the Navitus Health Solutions website linked to in the “Forms & Resources” section below. Or call Navitus to request your ID card be sent to you via U.S. Mail.

Benefit Premiums

Pharmacy Benefit premiums are included in the State Group Health Insurance premium. For State Group Health Insurance premiums review the Benefit Premiums web page.

Forms & Resources

• Certificate of Coverage for Pharmacy Benefits pdf
• Comparison of Health & Pharmacy Benefits pdf
• Navitus Formulary List pdf
• Terms and Conditions
• Navitus Health Solutions | (866) 333-2757