You must use an in-network pharmacy. In-network pharmacies are available nationwide. Visit etf.benefits.navitus.com to find an in-network pharmacy near you. 

Prescription Deductible

None

Prescription Copay/Coinsurance

Level 1 

 

$5 or less

Level 2 

20% ($50 max)

Level 3 

40% ($150 max)

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

Level 4 specialty 

$50 copay

Must fill at Lumicera Health Services specialty pharmacy or UW Specialty Pharmacies.

Preventive prescription copay

Plan pays 100%, regardless of deductible

Prescription Out-Of-Pocket Limit

Levels 1 & 2 

Individual / Family

 

$600 / $1,200

Level 3 

Individual / Family

$6,850 / $13,700

Level 4 

Individual / Family

$1,200 / $2,400