1. What is a Pharmacy Benefit Manager (PBM)?

A PBM is a third-party administrator of a prescription drug program that is primarily responsible for processing and paying prescription drug claims. In addition, they typically negotiate discounts and rebates with drug manufacturers, contract with pharmacies, and develop and maintain the drug formulary.

A PBM also provides programs designed to help members maintain or improve their overall health by working closely with the member and their doctor to ensure the drugs members take are safe and effective.

Navitus Health Solutions is the PBM for the State of Wisconsin Group Health Insurance Program.

2. What is a formulary? How is it developed? How will I know if my prescription drug is on it?

A formulary is a list of prescription drugs that are determined to be both medically effective and cost-effective by a committee of physicians and pharmacists.

Drugs are evaluated based on their effectiveness, side effects, drug interactions, and then cost. Drugs are reviewed on a continuous basis to make sure the formulary is kept up to date, and that patient needs are being met.

You can find the complete formulary on Navitus's public-facing website (no login required) or by logging in to Navitus's Member Portal. You must be registered to access Navitus's member portal. You may also call Navitus's Customer Care toll-free at 1-866-333-2757 with questions about the formulary.

The Navitus MedicareRx plan (Medicare Part D) formulary is established by the Centers for Medicare & Medicaid Services (CMS), a federal agency within the United States Department of Health and Human Services.

If you are enrolled in the Navitus MedicareRx plan (Medicare Part D), you can access the Navitus MedicareRx plan formulary either on Navitus's public-facing website (no login required), through the "Members" section on the Navitus MedicareRx website, or you can call the Navitus MedicareRx team at 1-866-270-3877.

3. How does a four-tier drug benefit work?

Your drug benefit has four different tiers, levels 1 through 4. Drugs are divided between those levels, and you will pay different amounts for a drug based on its level. The lower the level, the less you pay.

Your plan encourages you to use preferred formulary drugs by having a lower copayment or coinsurance for Level 1 and Level 2 drugs. Drugs listed at Level 3 have a coinsurance and are considered non-preferred drugs. These drugs are still covered but will cost you more money. Level 4 drugs are specialty drugs and have the largest amount of cost-sharing.

Copayments and coinsurance for Level 1 and Level 2 drugs count toward your annual Level 1/Level 2 out-of-pocket-limit (OOPL). Coinsurance for Level 3 drugs and Level 4 drugs do not count toward the OOPL, they only count toward the federal maximum OOPL.

For non-Medicare members, Level 4 drugs must be filled through either Lumicera Health Services Specialty Pharmacy (Lumicera) or UW Health Specialty Pharmacy (UW Health). With the exception of certain limited distribution drugs, specialty drugs will not be covered at other pharmacies.

For Medicare members, you may use Lumicera Health Services Specialty Pharmacy, UW Health Specialty Pharmacy, or you may use a different specialty pharmacy. If you use Lumicera or UW Health, your costs will be lower and will apply to your annual OOPL for specialty drugs.

Please note that some drugs are not covered on the same level on the non-Medicare formularies and the MedicareRx plan formulary. Some drugs may require prior authorization or have quantity limits on the MedicareRx plan formulary. Please check with your provider or contact Navitus to learn more. 

4. How does the prescription drug benefit work for specialty medications?

For non-Medicare members, preferred specialty prescription drugs are classified as Level 4 drugs when they are filled through Lumicera or UW Health specialty pharmacies. These drugs have a $50 copayment each time you fill the prescription and will count toward your federal maximum OOPL. Getting your drugs through Lumicera or UW Health will also give you access to programs that can help you manage your medications. Call Navitus at 1-866-333-2757 for more details.

Specialty drugs that are non-preferred, or specialty drugs filled outside of Lumicera or UW Health, will not be covered.

For Medicare members, specialty drugs are classified as Level 4 drugs. If you fill your prescriptions for preferred specialty drugs at Lumicera or UW Health, you will have a $50 copayment each time you fill the drug, and that copayment counts toward your Level 4 OOPL.

If you receive a non-preferred drug, or fill your prescription at a network pharmacy other than Lumicera or UW Health, you will have a non-preferred coinsurance of 40% (up to a maximum of $200), and that coinsurance will not count towards the Level 4 OOPL, only the federal maximum OOPL. Call Navitus at 1-866-270-3877 for more details. 

5. What is the specialty drug clear bagging program?

Clear bagging is a program where certain specialty drugs for non-Medicare members will be covered by the pharmacy benefit rather than the medical benefit.

Which drugs are a part of the program? Non-cancer specialty medications dispensed from the UW Health Specialty Pharmacy for non-Medicare members receiving care in the UW Health System.

How does this affect me? If you have a medication dispensed under the program, you will receive multiple explanations of benefit (EOB) statements. One from your health plan for the administration of the drug, and another from Navitus for the drug itself. 

This program will not impact your care. You will still have the drugs administered in the same location, by the same medical professionals as you would have had prior to your drug enrollment in the clear bagging program.

6. Will I have to use a different ID card when I go to the pharmacy?

Yes. You will have two identification cards: one from your health plan and one from either (a) Navitus Health Solutions or (b) the Navitus MedicareRx (PDP) plan (for eligible retirees enrolled in Medicare) for pharmacy benefits. When filling prescriptions, you must present your Navitus pharmacy benefits ID card to the pharmacist.

7. What will my prescription drugs cost?

The cost of prescription drugs can change frequently, sometimes even month to month. Navitus has a tool on its website that will tell you how much your drugs will cost at the specific pharmacy you go to.

Go to Navitus's Member Portal and set up an account, then click on Cost Compare to check the price of your drugs.

You can also view the most up-to-date formulary at Navitus's ETF Benefit website. No need to log in, just select your health insurance plan and view the formulary. The formulary lists every drug that is covered by your pharmacy benefit and which tier the drug is on. 

8. Why did I get a generic drug instead of a brand name drug?

To provide you with the best value, the Uniform Pharmacy Benefit requires that higher-cost brand name drugs be replaced by lower-cost generic equivalent or alternative drugs that have been proven to work like the brand name drug. In most cases, the brand name drug will not be a preferred drug on the formulary. If you cannot take the generic drug for medical reasons, your doctor will have to request an exception to coverage from Navitus.

Some doctors write prescriptions as “DAW-1,” or “dispense as written.” This means the pharmacist will fill the brand name drug as written on the prescription and will not substitute an available generic equivalent. You will pay more for “DAW-1” brand name Level 3 drugs unless you cannot take the generic equivalent drug due to a medical need. If you have a medical need, your doctor must submit an FDA MedWatch form for the prescription. Your doctor can contact Navitus for the form. Without the form, you will pay the 40% coinsurance plus the cost difference between the brand name drug and its generic equivalent. With the form, you will pay a 40% coinsurance (with a limit of $150).

Examples: 

Example 1: Level 3 "DAW-1", No Medical Need for Brand Name Drug

Your doctor prescribes you BrandNameStatin and marks it as “DAW-1”. You do not have a medical need, so your doctor does not submit the FDA MedWatch form

30-Day Supply Costs

Your Costs with Insurance:
BrandNameStatin: $1,250
Generic equivalent: $5

Cost Before Insurance:
BrandNameStatin: $2,000
Generic equivalent: $900

BrandNameStatin Cost Calculation

$2,000 x 40% = $800 → $150 
You pay 40% of the original drug price. There is a limit of $150
$2,000 - $900 = $1,100
You also pay the cost difference between the brand name drug and the generic equivalent
$150 + $1,100 = $1,250

When having a brand name drug is not medically necessary, you can save money by getting the generic. In this example, you’d save $1,245 each time you fill your prescription.
 

Example 2: Level 3 "DAW-1", Medical Need for Brand Name Drug

Your doctor prescribes you BrandNameStatin and marks it as “DAW-1”. The brand name drug is medically necessary because you are allergic to an ingredient in the generic equivalent. Your doctor submits the FDA MedWatch form to Navitus.

30-Day Supply Costs

Your Costs with Insurance:
BrandNameStatin: $150

Cost Before Insurance:
BrandNameStatin: $2,000

BrandNameStatin Cost Calculation
$2,000 x 40% = $800 → $150 
You pay 40% of the original drug price. $800 is higher than the max, you are only responsible for $150.