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.