Pharmacy benefits are included with your health benefits.

You must use an in-network pharmacy. In-network pharmacies are available nationwide.

Prescription Deductible Included in medical deductible .

Level 1

After deductible: $5

Level 2

After deductible: 20% ($50 max)

Level 3

After deductible: 40% ($150 max)

Level 3 “Dispense as Written” or “DAW-1” drugs may cost more. See example

Level 4 specialty

After deductible: $50 copay (Must fill at specialty pharmacy)

Preventive prescriptions

Plan pays 100%, regardless of deductible

Preventive Drugs

“Zero Dollar” preventive drugs identified by the Affordable Care Act (ACA) are paid for by the program even if the deductible has not been met. You can find a list here.

A list of fully covered contraceptives can be found here.

“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 copayment /coinsurance until the OOPL is met. You can find a list here.

These lists may change at any time. You can find the most up-to-date lists here.

Prescription Drug Formulary

You can find a list of the current formulary  here. You can also log into Navi-Gate® for members through this page to search for your prescription drugs on the formulary. 

Prior Authorization Requirements

Some prescription drugs require a prior authorization for it to be covered by the program. 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. Learn more about drugs requiring prior authorization here.

Diabetic Supply Coverage

Diabetic supplies and glucometers are covered; you will pay 20% coinsurance as long as you get your supplies from an in-network supplier. Contact Navitus Customer Care if you need help finding one.

If you are a High Deductible Health Plan participant , you will need to meet your deductible first.

90-Day-at-Retail Program

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 copayments are still required. More information can be found on the Navitus website or by calling Navitus Customer Care.

Mail Order Program

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

RxCENTS Tablet-Splitting Program

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 copayments. 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.

Specialty Medication Program

(Level 4 Self-Injectables and Specialty Medications)
If you are taking a specialty medication, the Navitus SpecialtyRx Program is offered through both Lumicera Specialty Pharmacy and the UW Specialty Pharmacy for non-Medicare participants. Medicare participants have some additional pharmacy options.

Specialty medications are marked with “ESP” in the formulary.  To begin receiving your self-injectable and other specialty medications from the specialty pharmacy, please call Navitus SpecialtyRx Customer Care at 1-877-651-4943.

Coordination of Benefits

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 Group Insurance plan . Coordination of benefits does not guarantee that all your out-of-pocket costs will be covered

Level 3 "DAW-1" Examples

This does not apply to retirees with Medicare.

Some doctors write prescriptions as “DAW-1,” or “dispense as written.” This means the pharmacist will fill the brand name drug as written and will not substitute an available generic equivalent.

Starting in 2019, you will pay more for “DAW-1” brand name level 3 drugs unless you cannot take the generic equivalent due to a medical need. If you have a medical need, your doctor must submit a one-time FDA MedWatch form to Navitus for the prescription. Have your doctor contact Navitus for the form.

The FDA MedWatch form must be submitted the first time you are prescribed the medication. Under normal circumstances, the form will be processed within 72 hours. For urgent/emergent situations, the form will be processed within 24 hours. After the form is submitted, it will stay on file with Navitus. Your doctor will not need to resubmit the form.

Without the form, you will pay the 40% coinsurance plus the cost difference between the brand name drug and its generic equivalent. See the examples below for more explanation.

Example 1: Level 3 "DAW-1", No Medical Need for Brand Name Drug

Your doctor prescribes you BrandNameStatin and marks it as “DAW-1”. You do not have a medical need so your doctor does not submit the FDA MedWatch form

30-Day Supply Costs

Your Costs with Insurance

  • BrandNameStatin: $1,250
  • Generic equivalent: $5

Cost Before Insurance:

  • BrandNameStatin: $2,000
  • Generic equivalent: $900

BrandNameStatin Cost Calculation

$2,000 x 40% = $800 → $150 
You pay 40% of the original drug price. There is a limit of $150

$2,000 - $900 = $1,100
You also pay the cost difference between the brand name drug and the generic equivalent

$150 + $1,100 = $1,250

When having a brand name drug is not medically necessary, you can save money by getting the generic. In this example you’d save $1,245 each time you fill your prescription.

Example 2: Level 3 "DAW-1", Medical Need for Brand Name Drug

Your doctor prescribes you BrandNameStatin and marks it as “DAW-1”. The brand name drug is medically necessary because you are allergic to an ingredient in the generic equivalent. Your doctor submits the FDA MedWatch form to Navitus.

30-Day Supply Costs

Your Costs with Insurance

  • BrandNameStatin: $150

Cost Before Insurance:

  • BrandNameStatin: $2,000

BrandNameStatin Cost Calculation

$2,000 x 40% = $800 → $150 
You pay 40% of the original drug price. $800 is higher than the max, you are only responsible for $150.

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