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. 

 

IYC Health Plan & Access Plan

 High Deductible Health Plan (HDHP) & Access HDHP

Prescription Deductible

Individual / Family

None

Combined medical & pharmacy:

$1,500 / $3,000

You pay 100% of most pharmacy costs until deductible is met.

Prescription Copay / Coinsurance

Level 1

 

$5 or less

 

After deductible: Up to $5

Level 2

20% ($50 max)

After deductible: 20% ($50 max)

Level 3 

40% ($150 max)

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

After deductible: 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.

After deductible: $50 copay 

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

Preventive prescriptions

Plan pays 100%, regardless of deductible

Plan pays 100%, regardless of deductible

Prescription Out-Of-Pocket Limit

Levels 1 & 2 

Individual / Family

 

$600 / $1,200

Combined medical & pharmacy: 

$2,500 / $5,000

Level 3 

Individual / Family

$6,850 / $13,700

Combined medical & pharmacy: 

$2,500 / $5,000

Level 4 

Individual / Family

$1,200 / $2,400

Combined medical & pharmacy: 

$2,500 / $5,000