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.