Breakdown of Your Pharmacy Costs

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.

Please note that if you are changing your health insurance coverage from IYC/Traditional or HDHP to Medicare Part D the coverage and requirements for some drug may change. Check the MedicareRx Plan formulary at etf.benefits.navitus.com to see how your drugs will be covered.

Prescription Deductible	None
Prescription Copay / Coinsurance Level 1	$5
Level 2	20% ($50 max)
Level 3	40% ($150 max)
Level 4 specialty	$50 copay¹ (If filled at Lumicera Specialty Pharmacy or UW Specialty Pharmacy.)
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

¹If you fill a Level 4 Specialty prescription at a non-preferred specialty pharmacy (listed above) you will pay 40% ($200 max). The amounts paid will not apply to the Level 4 OOPL, rather, to a federal limit of $6,850 individual / $13,700 family.

Pharmacy Specifics

Pharmacy Formulary

The formulary is a the list of all the drugs and supplies that are covered by the benefit.

In-Network Pharmacies

The Uniform Pharmacy Benefit only covers prescriptions filled at in-network pharmacies.

Vaccines at the Pharmacy

Get vaccinated at any in-network pharmacy using your pharmacy benefit.

Mail Order Pharmacy Benefits

Serve You works with Navitus and provides mail order prescription drugs that can be mailed directly to anywhere in the United States.

Specialty Medication Programs

Level 4 self-injectables and specialty medications are available through specific pharmacies for non-Medicare members while members on Medicare have some additional pharmacy options.