Visit etf.benefits.navitus.com to find an in-network pharmacy near you. In-network pharmacies are available nationwide. All It's Your Choice Medicare plan designs have the same pharmacy benefits.

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 

 

Up to $5

Level 2 

20% ($50 max)

Level 3 

40% ($150 max)

Level 4 

$50 copay1 (If filled at Lumicera Specialty Pharmacy or UW Specialty Pharmacy.)

Preventive prescription copay

$0 - Plan pays 100%, regardless of deductible, as federally required

Prescription Out-Of-Pocket Limit

Levels 1 & 2 

Individual / Family

 

$600 / $1,200

Level 3

Individual / Family

$8,700 / $17,400

Level 4 

Individual / Family

$1,200 / $2,400

1Price if you fill at Lumiceria speciality pharmacy or UW Health Speciality Pharmacies. If you do not fill at one of these pharmacies, you will pay 40% ($200 max). The amounts paid will not apply to the Level 4 OOPL, rather, to a federal limit of $8,700 individual / $17,400 family.